Work and Health: Risk Groups and Trends Scenario Report Commissioned by the Steering Committee on Future Health Scenarios

Work and Health: risk groups and trends

Research team of TNO Institute of Preventive Health Care Researchers: A. Bloemhoff, M.Sc. Dr. P.G.W. Smulders Scenario Committee on Work and Health Chairman: Dr. P.A. van Wely

Work and Health risk groups and trends Scenario report commissioned by the Steering Committee on Future Health Scenarios

1994 Kluwer Academic Publishers Dordrecht - Boston - London

Distributors for the United States and Canada: Kluwer Acadennic Publishers, P.O. Box 358, Accord Station, Hingham, MA 02018-0358, USA for all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 3300 AH Dordrecht, The Netherlands Steering Committee on Future Health Scenarios P.O. Box 5406 2280 HK Rijswijk The Netherlands Telephone (31-70) 3407205 Translation of the Dutch original 'Arbeid, gezondheid en welzijn in de toekomst' by E.W. Bergsma, M.A.

ISBN 0-7923-2733-0 © 1994 STG, Rijswijk All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or othenA/ise, without the prior written permission of the publishers. Kluwer Academic Publishers, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. PRINTED IN THE NETHERLANDS

TABLE OF CONTENTS

Page

Preface Summary

1

1 1.1 1.2 1.3 1.4

5 5 7 8

1.4.1 1.4.2 1.5

Introduction Why examine the future of work and health? How should the future be studied? Aim of this study First phase: description of the recent past and present situation Data sources used The social security system in the Netherlands Second phase: exploration of the future

9 9 11 14

2 2.1 2.2

How to define 'work' and 'health' What do we mean by 'work'? What do we mean by 'health'?

17 17 18

3

Theory: the quality of working life, work capacity and health The relevance of work for health The macro-determinants of the quality of working life The quality of working life: stressors at work Work capacity: the coping ability of working people The effects of work on health and well-being Working life, work capacity and health combined in a model

23 23 26 27 27 28 30

3.1 3.2 3.3 3.4 3.5 3.6 4 4.1 4.2 4.3 4.4 4.5 4.6

The macro-determinants of the quality of working life Introduction The economy as a determinant of the quality of working life Technology as a detemiinant Occupational health care as a detenninant Dutch government policy as a determinant of working conditions Summary and conclusions

33 33 33 35 39 42 45

Page 5 5.1 5.2 5.2.1 5.2.2 5.2.3 5.3 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.3.6 5.3.7 5.3.8 5.3.9 5.4 5.5 5.5.1 5.5.2 5.5.3 5.5.4 5.6 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7

The quality of working life in the Netherlands Introduction Job content Monotonous work/short cycled work Training and experience in relation to the actual job content Work pace Working conditions Heavy physical work Noise at work Vibrations and shocks Climate and the Sick Building Syndrome Radiation Chemical agents and working conditions Biological agents and working conditions Dirty work Unsafe working conditions/dangerous work Labour relations Employment conditions Promotion possibilities/prospects Length of working hours New work patterns/work contracts Shift work Summary and conclusions Characteristics of the working population in the Netherlands Introduction The population and the labour force in the Netherlands Age Sex Education Norms and values about work Summary and conclusion

47 47 49 49 51 52 52 52 54 56 57 58 58 60 61 62 63 64 64 66 68 68 70 73 73 73 74 76 76 77 78

Page 7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8

The health of the working population Introduction Opinions of working people about their own health Visits to GP's and the use of medicines by working people Sickness absence Prolonged employment disability Occupational diseases and disorders related to work Occupational accidents Summary and conclusions

8

The future of work and health: introduction and methodology The Delphi method in general The seven scenarios of the Delphi study Work and Health The selection of four industrial branches The experts consulted (members of the panel) The questionnaires used The questionnaire for the first Delphi round The questionnaire for the second Delphi round Method of analysis of the answers to the questionnaires The quality of the results of the Delphi study The homogeneity of the answers of the experts Impact of the feedback from the first round on the answers in the second round Influence of experts' occupation on the responses Influence of self-selection of the expert and the degree of expertise on the answers Summary

8.1 8.2 8.3 8.4 8.5 8.5.1 8.5.2 8.6 8.7 8.7.1 8.7.2 8.7.3 8.7.4 8.8 9 9.1 9.2 9.3 9.4 9.5 9.6

Results: the six exploratory scenarios Introduction The six exploratory scenarios compared Favourable and unfavourable developments in the quality of working life 1983/1986 - 2010 Favourable and unfavourable developments in health 1983/1986 - 2010 The differences in work and health between the four industrial branches 1983/1986 - 2010 Summary

79 79 79 83 84 87 92 97 98 101 101 102 104 104 106 106 110 111 112 112 113 113 114 116 119 119 119 121 129 132 134

Page 10 10.1 10.2 10.3 10.4 10.5

Results: the goal-oriented scenario Introduction Setting priorities in the nine policy areas Concrete measures in the three most important areas The costs of the proposed measures Summary

11

Future projections of sickness absence and work disability Introduction Influence of economic developments on sickness absence and employment disability until the year 2010 Influence of the demographic distribution of the working population on sickness absence and employment disability until the year 2010 Summary, discussion and conclusions

11.1 11.2 11.3 11.4 12 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9

Summary and final reflections Aim and relevance Recent developments in the area of work and health Differences between age groups and between men and women Differences between industrial branches today and in the future What do the scenarios have in common? Influence of the state of the economy on the future of work Influence of policy measures on the future of work and health How should sickness absence and employment disability be tackled? Policy recommendations

137 137 137 139 141 142 145 145 146 150 153 157 157 158 161 163 166 169 171 173 177

Literature

181

Abbreviations

197

PREFACE

This book is an edited and updated version of the report 'Arbeid, gezondheid en welzijn in de toekomst; toekomstscenario's arbeid en gezondheid 1990-2010' commissioned by the Steering Committe on Future Health Scenarios and published by Bohn, Stafleu and Van Loghum, Houten/Antwerp in 1991. The authors wish to express their grateful thanks for the constructive comments they received from many people during the writing of this book. The following persons, however, deserve to be mentioned by name: E.W. Bergsma M.A., Prof. F.J.H. van Dijk, Dr. C.L. Ekkers, Prof. F. Huygen, Dr. M.A.J. Kompier, Prof. J.P. Mackenbach, Dr. P.A. van Wely and Dr. J.H.B.M. Willems.

SUMMARY

Aim and scope of the study The main aim of this book is to show how the field of work and health will develop until the year 2010 under certain economic and other conditions. This is done on the basis of a Delphi study carried out with the cooperation of 120 leading experts in the Netherlands. A secondary aim was to investigate the present state of work and health in the Netherlands with the aid of available statistical sources. We think that this book is relevant to policy-makers in government and in industry. The book will also provide material for discussion and policymaking, not only for personnel managers, occupational hygienists, company doctors, insurance physicians, safety officers, and ergonomists, but also for managers and members of works councils at company level. The book focuses on that part of labour that is involved in paid employment. A broad definition of health has been chosen, similar to that which is generally used in industry. Both physical and mental health (described for example in terms of back complaints and stress,) and health behaviour (described in terms of visits to GPs, use of medication, sickness absence and long-term employment disability,) wiU be discussed. The book assumes a 'classic' model in which the quality of working life (job content, working conditions, labour relations and employment conditions) is considered the main determinant of the health and welfare of the working population. The present A number of developments in the quality of working life in the 1970s and 1980s can be easily recognized. These relate to the unfavourable aspects of working conditions. Exposure to vibration and shocks has decreased in time, as have dangerous work, noise, dirty work and unpleasant smells at work. Labour relations ('human relations') appear to have improved in the last two decades, and the workload has been lessened by a decrease in working hours. The following trends may be considered negative: educa-

tion is less well related to job content, the work pace has risen and there is more heavy physical work. In short, we have seen an improvement in the 'classic' working conditions but a worsening of the 'work-stressors' in the past 15 years. In the past 10 to 15 years there has been a small increase in the number of working people who state that their own health can be described as good or very good. This does not go together with a corresponding decrease in backache and fatigue. The percentage of working people who sometimes suffer from headaches has fallen significantly. The number of visits to GPs has remained the same, while contact with specialists has decreased, as has the use of medication. Trend data on sickness absence and employment disability relating to the last 15 years show that the rate of sickness absence in manufacturing fell from about 9% to 6%; the percentage of people being declared disabled for work (per 100 insured per year) fell from 2.3% to 1.4%. The available data seem to indicate that the health of the working population in the Netherlands has improved somewhat in the recent past. This is probably due to selection and outflow mechanisms, and to improvements in the quality of working life. The future The future developments in the area of work and health have been explored by means of a so-called Delphi study carried out with a panel of 120 experts in the first round and 88 experts in the second. They were presented with questions about the possible future of work and health given some six scenarios: high, medium and low economic growth, improvement in working conditions, extension of occupational health care, and intemationalisation of economic life. The results may be summed up as follows. The quality of working life will develop to a certain extent independently of the economic developments and policy interventions in the coming 20 years. On the whole it will improve. Economic developments and policy measures, however, accelerate or decelerate these more or less autonomous developments, sometimes rapidly. In general the favourable future trends are concerned with physical working conditions (noise, dangerous work, exposure to toxic materials.

vibration and shocks, heavy physical work) and with labour relations and employment conditions. The unfavourable trends are mainly related to stress factors, (work pace, time pressure, working in shifts, lack of close correspondence between level of education and job content, mentally demanding work). For the future we therefore see on the whole a continuation of the developments that have been taking place in the past 15 years. What are the implications of these findings? Policy, health care and research will have to concentrate on the weU-being and mental health of the working population instead of on physical health. And as for the approach to be followed: an improvement in working conditions and occupational health-for-all have clearly the best effects on all fronts from the policy point of view. They will have a limiting effect on the psychological stressors at work, as well as on ergonomic and toxicological problems. Influencing the favourable development of the Dutch economy by appropriate economic policy measures will have less direct influence on the quality of working life than the above measures. It appears, however, that high economic growth has a more favourable effect in general on the quality of working life than low economic growth: growth has a favourable effect on physical workload, employment conditions and labour relations. On the other hand, high economic growth leads to more time pressure and mentally demanding work. What is there then to say about future health developments in the working population? The policy scenarios are favourable for all health indicators and especially so for bringing down back complaints, sickness absence and employment disability. With extensive policy intervention the rate of sickness absence could fall from 7.5% in recent years to 5.5-6% in the year 2010. The rate at which people become disabled for work could be diminished by a third in the policy scenarios. According to the experts consulted, low economic growth leads to a small increase in health problems linked to the work situation, although to a decrease in the rate of sickness absence. With high economic growth they expect this rate to increase.

How can the rate of sickness absence and employment disability be halved by the year 2010? Taking as a goal the halving of the rate of sickness absence and employment disability in the period till 2010, the study carried out with Dutch experts suggests that an improvement in working conditions and occupational health-for-all have great importance. But there is a set of measures which the experts consulted find even more important in reaching this goal. These are measures related to social security legislation and regulation. In practical terms this means introducing more premium differentiation between employers and between employees in the Sickness Benefits and Disability Insurance Acts, reward/punishment systems, own riskbearing for employees and employers, stricter assessment of the degree of employment disability of employees and stricter administration of the Sickness Benefit Act, etc. In short, improvements in the quality of working life and in the corresponding state of health of the working population do not happen by themselves. Intensifying and expanding policy-making in the area of improvement of working conditions, occupational health care and social security regulation is to be recommended.

INTRODUCTION

1.1

Why examine the future of work and health?

From the beginning of time humankind has tried to see into the future. Attempts have been made to predict the outcome of wars, harvests and distant travels. In ancient times the Oracle of Delphi was consulted. The need for insight into possible future developments is as great now as it has ever been, although nowadays we are more interested in traffic problems, the environment and the construction of cities, etc. In the field of work and health, a vigorous social and political debate broke out in the Netherlands at the end of the 1980s and early 1990s concerning the level of sickness absence and employment disability, which were widely considered far too high. In 1990 the rate of sickness absence was 8.1% of all available working days (SVr, 1991), and nearly 900,000 people were declared disabled for work (out of a working population of around 6.5 million). Some contend that this is due to the poor quality of working life in certain branches of industry. The high pressure of work and the great technological changes are often blamed for this. Others point to the large demographic changes which are taking place in industry, such as the ageing of the working population and the fact that more and more women turn to the labour market and do not find suitable jobs there. Finally some people consider that the social security regulations in the Netherlands are so favourable (employment disability benefits are higher than unemployment benefits) that they are open to abuse and misuse. Many people wonder how the quality of working life will develop in the next decades. Will the adverse health effects of working with toxic materials be eliminated by the year 2010? Will the assembly line continue to exist? Where will the advances in automation lead to? All things considered, there is more than enough reason to concern ourselves with the future of work, health and well-being.

In the past years a great many Dutch prospective studies have been carried out in the field of health and health care, on such varied topics as ageing, cancer, cardio-vascular diseases, accidents and mental health, to mention but a few. Some of these topics, such as the ageing of the population, industrial accidents and employment disability due to mental disorders (STG, 1985, 1989, 1992), touch on our theme 'Work and Health'. Research on the future of work has also been carried out in the Netherlands and abroad. Future studies on the theme of work in the Netherlands have been mainly centred on the supply and demand of labour, in both a quantitative and qualitative sense: for example, 'Information technology and employment' (SoZaWe, 1986) and 'The labour market by educational category 1975-2000' (CPB, 1987). Studies have also been made on the future orientation of work, such as the report 'Some aspects of work in the future' (Becker & Vink, 1986), and labour relations in 'Contemplations about the future of the social partners' (Reynaerts, Fase & De Boer, 1985). The most important factors influencing the future of work and the workforce are demographic, economic, technological, social and cultural developments (WRR, 1988). These topics are also discussed in international studies about the future of work. Examples include 'Work in America; the decade ahead' (Kerr & Rosow, 1979), 'The changing composition of the workforce: implications for future research and its applications' (Glickman, 1982), 'Sleepers, wake! Technology and the future of work' (Jones, 1982), 'Education, unemployment and the future of work' (Watts, 1983), 'The future of work' (Handy, 1985), 'Fabrik 2000; alternative Entwicklungspfade in die Zukunft der Fabrik' (Brodner, 1985), 'Work in Europe, five possible scenarios' (Van der Werf, 1987), 'Projections 2000' (Bureau of Labor Statistics, 1987), 'Quitting time: the end of work' (Macarov, 1988), 'The changing workplace' (McDaniels, 1989) and 'Future Work, seven critical forces reshaping work and the work force in North America' (Coates et al, 1990). In the field of work and health in the future, the only publication that has appeared in the American literature is, as far as we know, the book 'The future of work and health' (Bezold et al, 1986). Future developments in work are examined by these authors in terms of demographic, economic, technological, social and cultural developments. Future developments in health and health care are also examined, but are not explicitly related to work.

'Work and Health' as an interrelated topic has never before been the theme for an exploration of the future. The present future scenario study, carried out at the request of the Steering Committee on Future Health Scenarios in the Netherlands (STG), is the first study in the Netherlands on that subject and may also be so internationally. We have, we hope, given enough arguments for the relevance of such a study. 1,2

Hov»^ should the future be studied?

The methods used to gain an insight into the future have changed considerably since the Oracle of Delphi; modem research on the future adopts a scientific approach (Becker & Dewulf, 1990). This modem approach was developed during and after World War II and was directed primarily to military strategy. In the 1960s and 1970s long-range research was carried out by government and industry. Dutch government bodies that are or have been concerned with such research include the Central Planning Office (CPB) (for economic predictions), the Social and Cultural Plarming Office (SCPB) (for explorations in the social and cultural sphere), the Central Bureau of Statistics (CBS) (for population projections) and the Scientific Council for Government Policy (WRR) (for general and policyoriented explorations on the future). In industry. Shell and Philips are examples of companies that have conducted future studies. The predictive value of various future studies was evaluated at the end of the 1970. The general conclusion was that their predictive value was too limited, and that uncertainties were not sufficiently taken into account. As a result, research on the future took a new course. Instead of one future, a number of possible altematives were sketched, and the so-called scenario method was bom (STG, 1986). Scenarios may be defined as: 'descriptions of the current situation in society (or part thereof), of potential and desirable future situations and of series of events which could lead from the former to the latter, with the purpose of obtaining a better insight into the underlying mechanisms and the possibilities of influencing them' (STG, 1986). In a scenario study a number of possible representations of the future are developed with the aid of scenarios. In short, a scenario study does not forecast, but explores possible futures.

In the literature on this subject, distinctions are made between various types of scenario. These are classified and named differently by various authors (see, for example, STG, 1986 and Bezold, 1991). In this report we distinguish between different sorts of scenarios. Firstly there are exploratory scenarios, which, starting from a consideration of the present situation, hypothesize a number of possible future developments. These scenarios can be further subdivided into autonomous scenarios, which examine the influence of more or less autonomous factors, and policy scenarios, which describe the future situations that may result from policy intervention. Secondly, there are scenarios that set targets. In these scenarios, effective strategies are sought for achieving a desirable future situation. Future developments can be explored on the basis of the expectations of experts and on the basis of extrapolations. Both methods are used in this scenario study. 1.3

Aim of this study

The ultimate aim of the future scenario study Work and Health is to stimulate public discussion about the future of work and health and to give a better foundation for policy proposals. In the light of this, two questions are formulated which need to be answered in this study: 1. What are the present factors in the work situation that can adversely affect the health, safety and well-being of the workforce, and what is the prevalence of those factors (for the groups at risk) in the working population of the Netherlands? 2. How wiU the prevalence of the relevant risk factors in the work situation (together with the accompanying health effects) change in the period up to the year 2010, as a consequence of both 'autonomous' developments and policy measures? The first question will be answered in Chapters 2 -7 of this report, in which a description is provided of the developments in the recent past and present in the field of work and health. The second question is dealt with in Chapters 8 - 1 1 , where the second phase of the research, directed to the future of health and work, is described. A summary and some final reflections on the future of work and health will be given in Chapter 12.

1.4

First phase: description of the recent past and present situation

First the scope of the field of work and health will be demarcated and the concepts defined. At the same time a simple model will be constructed, incorporating the most important elements and their interrelations, namely 'the macro-determinants of the quality of working life', 'the quality of working life', 'the working capacity of the workforce' and 'the health and well-being of the workforce'. The framework of the scenario study is set up on this basis. The review then describes trends in these elements from the past to the present and also examines the groups of employees at risk. The review can be considered as the starting point from which the future can be explored. 1.4.1 Data sources used A great many data sources were used for the description of the field of work and health from the past to the present. These do not, however, give a complete picture of the situation in the Netherlands. Zielhuis and Van Dijk (1989) name as limiting factors the fact that information on occupation is lacking in hospital and death records and that the present registration of occupational diseases is incomplete in quality and coverage. In order to give the most accurate possible picture of the present situation, numerous statistical sources, including those of the Central Bureau of Statistics (CBS) and the social security authorities, were consulted and relevant quantitative data gathered from the literature. The main criteria for selection of these data were that they should relate to different moments in time, be reasonably representative samples of the working population and be collected in a standardized way. The most important sources will be briefly discussed below. Life Situation Surveys (LSS) of the CBS During the period 1974-1986 the Central Bureau of Statistics commissioned a life situation survey every three years on a representative sample of about 4,000 people drawn from the Dutch population of 18 years and older. Each reference year a new cross-sectional sample was drawn, so that the data always relate to different people. The survey is based on interviews conducted in people's own homes. Table 5.1 in Chapter 5 shows the size of each sample, and the proportion of working people of 18 years and older within each sample. On average

this was 49% per year. All the data to be presented relate to this group. For the sake of completeness it should be mentioned that comparisons with other CBS data show that the sample of working people aged 18 years and over may be regarded as representative of the working population in the Netherlands (Bloemhoff Si Smulders, 1991). The Life Situation Survey gives information about the opinions of working people on certain aspects of their work and health. Data on the composition of the Dutch working population The Labour Force Sample Survey (in Dutch AKT) of the CBS gives information about the size and composition of the Dutch labour force and general population. These surveys (for which the data were also collected on the basis of interviews) were held every two years in the period 19731985. Before that period a population census was conducted by the CBS in 1960 and 1971, which also contained information about the (working) population. The definitions used in the population census with respect to the total labour force, the people actually employed and the levels of education differ somewhat from those used in the Labour Force Sample Survey. This is also the case with the Labour Force Survey (in Dutch EBB), the yearly enumerations which were conducted by the CBS from 1987 onwards as a replacement for the Labour Force Sample Surveys. General trends and developments in the size and composition of the labour force in the Netherlands in the period 1960-1987 can be illustrated, however, by a combination of the data from the population census, the Labour Force Sample Survey and the Labour Force Survey. Data on sickness absence and long-term employment disability Several institutions provide data on sickness absence in the Netherlands. - Within the context of the Sickness Benefit Act to be described below, the Social Security Council (SVr) reports on sickness absence in all firms that are members of an industrial association (i.e. roughly 90% of all employees, excluding civil servants). The data are published in their yearly report approximately two years after the reporting period. - The TNO Institute of Preventive Health Care (NIPG/TNO) regularly publishes information about the participants in its own statistics on sickness absence (200 firms with approximately 200,000 employees) via the CBS and its own publications. This survey mainly covers large firms and not all industries are equally as well represented. - The Netherlands Institute for Working Conditions (NIA) reports yearly about the participants in its own information system on sickness absence (with a working population of circa 80,000). Not all industrial 10

branches are equally represented in this sample and medium-sized firms are overrepresented. As a result there are no statistics in the Netherlands which are completely representative of sickness absence in the country as a whole. The data from the Social Security Council (SVr) provides the most representative picture, although neither civil servants nor self-employed persons are included in the survey. Unfortunately these statistics have a long lag-time in comparison with the others. In this study, therefore, statistics will be used from all three sources mentioned above. The Joint Medical Service (GMD) and the Disability Insurance Funds (AAf/Aof) publish statistical information about long-term employment disability. The data from the Disability Insurance Funds relate to all benefits, divided into four population categories, namely: (1) wage earners (insured via the WAO), (2) civil servants, members of the armed forces and the employees of the Dutch railways (insured by the ABP), (3) the self-employed and members of their family who participate in their work (insured via the AAW only) and (4) persons handicapped before starting work and others (also only insured through the AAW). The second category (civil servants, forces and employees of the Dutch railways) is not included in the statistics of the Joint Medical Service (GMD). Both sets of statistics (GMD and AAf/Aof) go back as far as 1967, when the Disability Insurance Act came into force. The AAW came into force in 1976, and the number of long-term disabled consequently increased considerably in that year. In this report statistics will be cited from both sources. 1.4.2 The social security system in the Netherlands For a proper understanding of the situation in the Netherlands a short explanation of the Sickness Benefit Act (ZW) and the Disability Insurance Act (WAO) will be given. The passage below has been adapted from the article 'Health care facilities and work incapacity: a comparison of the situafion in the Netherlands with that in six other West European Countries' by Soeters and Prins (1985) and from the dissertafion 'Economic aspects of disability behaviour' by Aarts & De Jong (1990).

11

Since 1967, no important distinctions have been drawn between the causes of employment disability within the social security system in the Netherlands; the same Sickness Benefit and Disability Insurance Act apply, irrespective of the causes of temporary or permanent incapacity. The Sickness Benefit Act provides income replacement in cases of temporary incapacity for work lasting up to a maximum of 12 months. The level of benefits currently comprises 70% of gross pay, with a fixed maximum. Most collective labour agreements provide a 100% replacement. The authenticity of work incapacity is assessed by a social insurance physician. Non-medical employees of the industrial associations may visit the sick person in the first few days of absence, to act as a deterrent against malingering and to make selections for medical control. General practitioners play no role in sickness certification in the Netherlands. Sickness absence is a complex phenomenon, whose operational definition includes any (accepted) claim under the Sickness Benefit Act. In practice, this means that almost any case of reported incapacity for work due to ill health may be considered as sickness absence. The scope of this definition is very wide and includes both illness and less serious conditions, as well as industrial accidents and maternity leave (12 weeks; since 1990, 16 weeks). The differentiation between certified and uncertified sickness absence, which is made in various countries, does not exist in the Netherlands. Whereas the maximum duration of a spell of sickness absence is one calendar year, the definition of employment disability in the Netherlands includes permanent incapacity for work (after one year of sickness absence), again irrespective of cause. After the mandatory waiting period of 12 months under the Sickness Benefit Act, one can apply for Disability Insurance benefits (Dl-benefits, in Dutch AAW/WAO). The risk covered by the Dl-programme, however, is more stringently defined as the income lost due to an individual's incapacity to perform his or her current work. Dutch law provides the following definition of employment disability: 'A person is partly or fully disabled for work if, as a consequence of illness or injury, he is no longer able to earn with his own labour that which healthy people with the same education and experience working in the same place (or in the close vicinity) usually earn.' As a consequence, qualification for disablement

12

status depends not only on physical and mental health status but also on education, work experience, previous income and other factors. The degree of disability is determined by measuring an applicant's 'earning capacity', i.e. the income a disabled person would be able to earn in commensurate work, expressed as a percentage of the income earned by healthy, but otherwise similar, persons. The degree of disability is, therefore, the complement of earning capacity. The first slice of Dl-benefits is provided under the General Disability Benefit Act (in Dutch A AW) enacted in 1976. The AAW-programme covers all residents, aged 18-64, whether employed in the private or public sector or self-employed. The level of AAW-benefit size is based on the social minimum. As well as AAW-coverage, privately employed workers enjoy supplementary coverage through the WAO-programme, which provides the second slice of Dl-benefits. Disability assessments are made by an independent body, the Joint Medical Service (JMS, in Dutch GMD). The relevant insurance boards are obliged to consult the JMS on matters of disability (AAW or WAO) insurance claims, whether for benefits or provisions in kind. The administration of work-related social insurance (Sickness Benefits, Disability Insurance) is delegated to 23 insurance boards, representing different branches of industry. These industrial insurance boards are managed by representatives of employer organizadons and trade unions. They have the discretion to develop autonomous benefit award policies. Collective strategies are set up through directives of the Federation of Industrial Insurance Boards. The Industrial Insurance Boards are supervised by the Social Security Council (SVR). Trade unions, employer organizations, and independent government appointees have equal representation in the membership of the Social Security Council. The Council carries out its supervisory responsibilities by issuing direcUves to the Industrial Insurance Boards. The Council also supervises the boards of the Disability Insurance Funds (in Dutch AAf/Aof). These boards make twice-yearly calculations of the payroll tax rates necessary to cover programme expenditures. As well as supervision, the Council also has advisory tasks. The government is obliged to consult the Council on certain matters of social security policy, one of which is the twice-yearly assessment of social insurance 13

premiums. The government, however, is not obliged to act on the Council's recommendations. Moreover, the Minister of Social Affairs and Employment determines independently how the burden of social insurance contributions will be distributed between employers and employees. 1.5

Second phase: exploration of the future

In the second phase of the scenario study (Chapters 8 to 11) an attempt will be made to gain a greater insight into future developments in the field of work and health by means of six scenarios. Delphi study The predictions of experts about possible future developments in the quality of working life and the health of the workforce have been collected by means of the Delphi method. This method is used in order to allow experts to form opinions on a number of topics (which need to be quantified) in the field of work and health by means of an exchange of expectations and ideas. This method differs from other group processes, in that there is no direct communication between the participants in the discussion; instead use is made of a number of sequenfial questionnaires drawn up by the researchers. The experts, who remain anonymous to each other, receive with each successive questionnaire a summary of the results of the previous round, including a statistical feedback on the answers of the group as a whole and the degree of mutual agreement. On the basis of this feedback, experts may wish to adjust their views or stick to their original opinion. The Delphi method was initially used to reach a consensus about the answers given by the experts. In recent years, however, the ultimate goal has shifted from consensus to 'a certain degree of stability' of the answers over time. If the experts' opinions scarcely alter after a few rounds, irrespective of whether a certain degree of consensus has been reached or not, the reiterative process can then be ended. Practice has shown that three rounds are usually sufficient to arrive at a stable group opinion. Furthermore extra rounds can lead to 'fiUing-in fatigue' on the part of the panel of experts. A number of eariier scenario studies carried out at the request of the Steering Committee on Future Health Scenarios in the Netheriands also used the Delphi method. In those studies two written questionnaires were used, followed by a third, oral round or workshop

14

(STG, 1989, 1992). The main reason for this third round was to discuss the consistency and plausibility of the final scenarios. In our scenario study two written rounds were held in the period between December 1989 and September 1990. Seven scenarios were examined, six exploratory and one target-setting. The idea of a third oral round was dropped because the possible extra returns from such an exercise were not deemed sufficient to justify the amount of time that would have to be spent on it. Extrapolations The second method used to explore future developments in the health of the workforce consisted of two different types of extrapolations into the future, namely: extrapolations from the sickness absence rates and the risk of employment disability in relation to the economic situation in the past, and extrapolations of these two indicators in relation to a changing composition of the labour force by age and gender. These extrapolations take into account different influencing factors and also lead to different future representations of the health of the workforce. The principle that several future possibilities need to be outlined (rather than just one version of the future) has been justified by these alternative extrapolations.

15

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HOW TO DEFINE 'WORK' AND 'HEALTH'

2.1

What do we mean by 'work'?

Work structures the day, ensures social contacts, provides an income and gives status and identity. The importance of work for the individual, and perhaps for his health too, is summed up, concisely, in this statement. The report entitled 'Some aspects of work in the future' by the Netherlands' Social and Cultural Planning Office (Becker & Vink, 1986) states that all definitions of work, however else they may differ, start from a common assumption that work is directed to the satisfaction of wants. Work considered in this way covers a broad range of activities. Work has, however, come to mean paid work. According to the report of the Social and Cultural Planning Office, this is the result of a number of factors, such as the growth of the market economy, the development of legal regulations concerning work and the institutionalization of social security. For this reason this concept of work as a means of analysing society has become obsolete. In order to be able to pinpoint social developments, it is important, according to the above report, to distinguish between different kinds of work. The monetized economy is composed of the formal, counted economy and the informal uncounted economy. Official paid work is part of the formal counted economy and is registered in the national accounts. In the informal economy, two kinds of unofficial work can be distinguished, neither of which are included in the national accounts. First there are the unpaid activities which usually have an official counterpart, e.g. household work, child care, voluntary work and subsistence agriculture. Then there are the activities in the black economy, which are forbidden on legal or taxation grounds. These include work for which no income tax and premiums have been paid and work that is forbidden, e.g. theft or drug-dealing. According to the report of the Social and Cultural Planning Office, about 4,500,000 working years were spent on official work in the Netherlands in

17

1981 and between 7,500,000 and 9,500,000 working years on unofficial work. The information about work in the black economy is scarce, fragmentary and on the whole unreliable. The Central Bureau of Statistics tentatively estimated that such activities may amount to 10-15% of National Income. The various experts consulted believe that work in the black economy, on which no income tax is paid, may increase substantially in the future. Tfie Dutch Working Conditions Act (passed by Parliament in 1980) defines in great detail the words employer and employee, but does not give a definition of work. From Section 2 we may deduce that the Working Conditions Act can be applied to all industrial organizations, including government services and small firms. All work that does not fall into the category of official paid work, however, lies outside the scope of the Working Conditions Act. Having looked at the definitions and the different forms of work in general, it is now necessary to indicate how the concept of work will be treated in the present scenario study. For a number of mainly practical reasons the definition of the working population chosen is a limited one, namely the official (i.e. paid) working population. Those doing unpaid work therefore faU outside the scope of this study, as do people who have dropped out of the labour force: the unemployed and employment disability benefit claimants. 2.2

What do we mean by 'health'?

From the time of Ancient Greece to the present day very different views have been held as to what constitutes health. The definition most often cited, and also most often criticized, is that of the World Health Organization: 'Health is a state of complete physical, mental and social weU-being, rather than merely the absence of disease and handicaps'. Health is here a state of well-being which can be interpreted and used in any number of different ways. In 1978, when the concept 'Health for all by the year 2000' was introduced, the WHO stated that health was meant to be 'a personal state of well-being... that enables a person to lead a socially and economically productive life...'.

18

Various authors have pointed out that objective criteria for establishing health cannot be given. The Memorandum Health 2000 ('Nota 2000') issued by the Dutch Ministry of Welfare, Health and Cultural Affairs (WVC, 1986, 10-11) states that health is not an absolute concept. The Memorandum further says: 'Health can be seen as an equilibrium situation which is determined by the circumstances in which people find themselves and by the capacity which they themselves possess, or which they acquire with the help of others, to resist disturbances. These disturbances can have their origin either in the body of the person (endogenous) or outside it (exogenous). In order to prevent disease, either the exogenous or environmental factors and/or the individual (endogenous) capacity for adjustment or self-care can be manipulated. Perceptions about health vary between people and may also vary with time. This is seen, for example, when one looks at the human life-cycle. Every age has its own threats and possibilities for defence.' The American medical sociologist Mechanic (1986) has pointed out that physicians and patients tend to use very different definitions of health. Physicians speak in terms of specific illnesses. Padents use more general terms with the accent on well-being, not being able to function well, etc. Susser et al. (1985) wrote that health can be defined in (1) organic, (2) functional and (3) social terms. In this context they discuss such concepts as disease, illness, sickness, impairment, disability and handicap. These authors further add that someone can be 'organically ill' without feeling ill. Various factory workers, for example, continue to work when suffering from severe bronchitis. The reverse is also true: there are examples of people who declare themselves, or are declared, disabled, when no illness can be established in the organic sense. It is necessary to look into some other health concepts relevant to the field of work and health. The terms safety, health and well-being are often mentioned in one breath, thereby implying that all three are outcome-measures by which work situations can be judged. But safety does not belong to this threesome, because one can only refer to safe or unsafe machinery or work situations which may or may not lead to occupational accidents. Safety can therefore be a characteristic of a work situation, but the outcome-measure is the

19

number or kind of industrial accidents. In this scenario study these concepts will be used in this way. While the concept of well-being is interpreted very differently, the Netherlands' Ministry of Social Affairs provides the following interpretation of 'well-being in relation to work': 'The concept of well-being in relation to work is not the same as the well-being of every employee, but contains only objective criteria of aspects of work which make it possible to come to a situation of well-being.' The Dutch Working Conditions Act is limited to 'well-being in relation to work'. The regulations concerning well-being in Section 3 of the Working Conditions Act can be traced back to objective criteria concerning the organization of work, the design of workplaces and the establishment of production and work methods. One can conclude that 'well-being in relation to work', as interpreted in the Working Conditions Act, is, like safety, a characteristic of the work situation rather than an outcome-measure. By contrast the concept of well-being which we use in this study is meant to be a measure of effects, and lies very close to well-being in terms of work satisfaction. Finally we need to discuss two very common concepts, namely physical and mental health. Clark (1981) says that there is scarcely any concept more difficult to define than mental health. Not only is the division between mental and physical health unclear; that between health and illness is also far from clear. We can also conclude that physical and mental health are definitely not defined by the same concepts. To cite Susser et al. (1985): on the whole physical health is defined more in organic tenns, and mental health more in functional and social terms. In the present study the words health and illness will be used in a broad sense, in contrast to Bezold et al. (1986) in their future study about work and health. The reason for this, as argued above, is that there is no need for a more precise definition. Industry as a whole uses a broad concept of health, where health complaints, sickness absence and long-term employment disability are usually the central issues, and where health is often considered analogous with 'being able to be productive at work'. Our broad definition is therefore necessary in order to be relevant to Dutch industry. Furthermore, empirical data would not be available in sufficient quantity if a narrow definition of health were to be used. By adopting a broad definifion we can make use of such data as the diagnoses of illnes20

ses established by physicians (as, for example, in the case of sickness absence and/or employment disability), opinions of employees about their own health in broad or more specific terms and reported behaviour due to illness in terms of absence from work, visits to the G.P. and hospital admissions. Central to our study will be the health aspects/indicators which are relevant for the workforce and industry in general: back complaints, stress reactions, sickness absence and more permanent employment disability.

21

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THEORY: THE QUALITY OF WORKING LIFE, WORK CAPACITY AND HEALTH

3,1

The relevance of work for health

In the previous chapter both work and health were separately defined. It is now necessary to ask ourselves whether work is really relevant for health. This question can be divided up into three parts: (a) is working healthier or unhealthier than being unemployed or disabled? (b) which healthpromoting and health-threatening effects emanate from work, and how do these effects compare with other environmental factors, such as the physical environment, traffic, life-style, housing etc.? (c) Which healthpromoting and health-threatening effects emanate from different aspects of work? The empirical chapter 5 will be devoted to answering this last question. Various authors have taken up the first question, i.e. what are the relative states of health of working people, the unemployed and those unable to work because of disability? Philipsen and Halfens (1983) compared married working men with nonworking men, matched in pairs by age, social class and degree of urbanisation of the locality and region. It turned out that people disabled for work were less healthy in terms of all health indicators. It also turned out that there were no significant health differences between working people and people who had been unemployed for more than six months. At the same time it is worth mentioning that on the basis of Dutch statistical material. Van Houwelingen et al. (1984) concluded that there was no relationship in the Netherlands at macro-level between unemployment on the one hand and death as a consequence of (for example) suicide, alcohol abuse and heart disease on the other. On the basis of a life situation survey conducted in 1982, Becker and Vink (1986) concluded that there were few differences in the health of the unemployed and employed; only the stress scores of the unemployed were higher than those of the employed. The subjective judgement of health differed little between the two groups. People who were disabled for work however, 23

appeared to be distinctly unhealthier than working people, both physically and mentally. They also used more medication. One might conclude from these findings that working is healthier than not working, but this conclusion would be premature. Many of the aforementioned (unhealthy) people who were disabled for work were until recently part of the workforce. They left it for health reasons. Or to put it differently: working people form a group that is continuously being selected on health grounds. A cross-sectional comparison between working and non-working people does not, therefore, give a proper insight into the question as to whether working is healthier or unhealthier than not working. In order to research this, a longitudinal (cohort) study would have to be carried out on a group of working people and a group of nonworking people over several decades. Such studies are not available. The second question posed at the beginning of this section was concerned with the relative influence of work in relation to other environmental factors. Sturmans et al. (1982; pp.5-9) also considered this question. They contended that there is little prospect of a satisfactory answer, and that the influences due to interactive processes (for example, between the work and home situation) cannot be unravelled. An important study relating to the question put above is that of Schellart (1989). He analysed the files of 380 people who had been declared disabled for work, and concluded that in 37% of cases the cause of disability was completely or partly linked to work; in 49% of cases the cause lay outside of work and in 14% of cases no conclusive statement could be made. Grtindemann et al. (1991) repeated this study with similar results. In a recent Dutch study (Dijkstra, 1990) a thousand Dutch people, ranging in age from 15 to 95, were asked which factors they considered the most threatening to their health. In a sequence ranging from most to least threatening the following were cited: the environment, cancer, an accident, violence, a nuclear disaster, heart disease and, in eighth place, stress. Working conditions came in twelfth place. The working people interrogated gave stress and working conditions a higher priority, namely fourth and fifth place respectively. Approximately one third of the working population sees work as a possible threat to its own health. A similar study was carried out in the United States in the 1970s which concentrated on life-enhancing rather than health-threatening factors 24

(Campbell et al, 1976). These authors distinguished 17 'domains of life experience' in their nation-wide research project. Around 2000 people reported their personal satisfaction in these 17 domains. The authors calculated the contribution of these 17 scores to the total variance in a general well-being index. Work satisfaction was placed fourth, after sparetime activities, family life and standard of living, but before satisfaction related to marriage,finances,friendship, place of residence, housing, etc. In the literature on stress one body of research has concentrated on 'lifeevents' and their influence on illness. Holmes and Rahe (1967) made a list of stressful life-events using the medical files of American naval personnel. 43 events were listed in order or importance. The highest scores were for 'death of spouse' and 'divorce'. Six life-events connected with work were listed, namely dismissal (8th place), reorganization of firm (15th), change of job (18th), change in responsibilities at work (22nd), difficulties with the boss (30th) and change in working hours or conditions (31st). These six life-events show something of the relationship between work and mental health. French et al. (1982) reported that occupational factors explain between 14% and 45% of the variance in 'strain' (mental health or stress reactions). If the term 'occupational title' is replaced by the term 'occupational factors', the age of the variance explained drops to between 2% and 6%. Karasek et al. (1987) used material from questionnaires on 8,700 Swedish employees to throw light on the present query. They concluded that work factors (such as workload, role conflicts, own control of tasks, etc) explain more variance in the reported bodily and mental health factors than nonwork factors (such as travel time, spouse working or not, children at home, problems at home). The problem with this and other studies is the biased selection of the work and non-work variables used. The relationship between working conditions and life-style factors and mortality among the working population has been researched by Fox and Adelstein (1978) on the basis of official British data. They concluded that work plays a role in 18% of all cases. With cancer this would be true in 12% of cases, with accidents 23%, with respiratory diseases 28% and with circulatory diseases 32%. Peto (1985) explored in greater detail what the groups of factors to which cancer deaths may be attributed. Peto estimated that 3-10% of all cancer 25

deaths in the United States and the UK can be attributed to 'occupation' and 'industrial products'. Heederik (1990) estimates that in 10-30% of cases of chronic non-specific lung diseases (CNSLD) work and occupational aspects are a contributory factor. Reviewing the three questions posed at the start of this section, we can now draw the following conclusions: (a) at first sight, working appears to be healthier than not working (see also Figure 3.1), but it is difficult to compare working and non-working people because the former are constantly being selected on health grounds; (b) work, together with other causal factors, has a significant effect on health; (c) factors which are threatening to physical and mental health are certainly present in work (see also Chapter 5). This indicates that research on the future of work and health can certainly be regarded as worthwhile. 3.2

The macro-determinants of the quality of working life

If we glance through the pages of the 'Manual of Occupational Diseases' by the Dutch physician Heijermans (1908), the text and the photos dating from the tum of the century tell us much about what working conditions were like at that time and how much has changed since then. Although there are a number of negative aspects to working life in the year 1990, the changes since the tum of the century represent improvements in many areas: much less work is carried out in deplorable conditions, wages are better and working hours have been reduced, as will appear from Chapter 5. These changes in the quality of working life are an effect of relatively autonomous developments in the fields of technology and economics, as well as of conscious policy decisions on the part of government, management, trade unions and medical and non-medical consultants and providers of care and advice. In handbooks about industrial and/or organizational psychology attention has consistently been devoted in recent decades to the influence of the work environment on the functioning of organizations and their employ26

ees. Katz and Kahn (1978) distinguish five work-environment aspects: (1) the information and technology aspect; (2) the economic aspect: competition, market relationships, raw materials and labour; (3) the political aspect: laws and regulations; (4) the societal aspect: norms, values, culture; and (5) the physical aspect: geography, natural resources and climate. Having placed work-environment aspects in some sort of context, we should mention that the following environmental characteristics (or determinants of the quality of working life) will be examined in Chapter 4: -

financial and economic developments (§ 4.2); technological developments (§ 4.3); developments in the field of health care for people at work (§ 4.4); developments in government policy with respect to the workforce and to the quality of work (§ 4.5).

3.3

The quality of working life: stressors at work

This chapter serves as a theoretical introduction to the main concepts used in this book, the most central of which is the quality of working life. Four dimensions are usually attributed to the quality of working life: job content, working conditions, labour relations and employment conditions. Zielhuis and van Dijk (1989) used this classification as a starting point for their discussion of stressors at work and of the corresponding health risks. Both these authors discussed the following stressors: chemicals, noise, vibration, climate, radiation, physically demanding work, shiftwork, mental workload, psychosocial demands and biological factors. In Chapter 5 the quality of working life will be discussed in greater depth, with special concentration on the developments in the quality of working life mentioned above, their health effects and the groups at risk. 3.4

Work capacity: the coping ability of working people

The concept of the quality of working life was discussed in the last secfion. This section deals with the concept of 'the coping ability of working people'. 27

Van Dljk et al. (1990) define the ability to cope as 'the totality of physical and mental capabilities of the worker at a given moment. This concerns the workers's actual and desired performance potential. Coping can also be described as the ability to achieve and to resist.' Coping ability will be examined in greater detail in Chapter 6. The focus will be on sex, age and level of education, as well as certain work values. 3.5

The effects of work on health and well-being

In discussions concerning the effects of work situations on the health, safety and well-being of working people, several indicators other than death and illness are often used. These include subjective health, health complaints, frequency of visits to a doctor, use of medicines, sickness absence and permanent employment disability. One reason why so many different indicators are used is that work does not generally sow 'death and decay' and that death and serious illness are not generally sufficiently sensitive indicators to measure the effects of work on the physical and mental well-being of working people. Another reason is that when a death is registered in the Netherlands, no record is kept of the employment or occupation of the deceased person. The relationship between work and death is therefore unknown in the Netherlands. Furthermore, several studies indicate that working people are a relatively healthy sample of the total Dutch population, as is shown in Figure 3.1 (based on the data from the Life Situation Survey of the CBS). One might conclude that our workforce is in fact overly healthy, given the numerous threats to health. This can be explained by the fact that a high proportion of adverse health effects manifest themslves among the nonworking population. Nearly 900,000 people were declared disabled for work in the Netherlands in 1990, representing one out of every 11 potential workers. This is the result of a 20-year 'weeding-out' process during which the sick, the less healthy and those who, for a number of reasons, are less able to cope were pushed out of working life. The process leads to a working population which is selected for health and working capacity: this can be traced back in the results of the Life Situation Survey presented.

28

Figure 3.1

Percentage of working and non-working people who do not consider themselves to be in good health. Source: CBS/Life Situation Survey, 1986

percentage

80 H

60 H

working people

housewives/ men

unemployed

disabled for work

There is a growing interest in government circles and among employers' and employees' organisations in policies aimed at lowering the drop-out rate from the workforce. This interest is mainly due to cost considerations. As Figure 3.2 shows, 10.1 billion guilders (approximately US $ 5 billion) were spent on sickness benefits and 21.0 billion guilders (approximately US $ 10.5 billion) on disability payments in 1990 for a working population of 6,000,000. These cost figures show the relevance of thinking about the future of work and health. Not included in these figures are the costs of the administration of benefits, the costs of medical consumption, and the indirect costs incurred by employers because of sickness absence, i.e. productivity losses and/or the costs of using temporary replacements. In Chapter 7 a detailed account will be provided of the way in which the various health indicators of the Dutch working population have developed in the last decades.

29

Figure 3*2

Payments made for sickness absence and employment disability (1970-1990), in billions of Dutch guilders. Source: CBS, 1971, 1981, 1988, 1990

billions Dutch guilders

1970 1980 1988 1975 1985 1990

1970 1980 1988 1975 1985 1990

H sickness benefits EH disability payments

3.6

Working life, work capacity and health combined in a model

In the last four sections four questions were discussed. These were: (1) What are the macro-detemiinants of the quality of working life? (2) How is the quality of working life defined? (3) What is meant by work capacity or coping ability of working people? (4) What are the health effects of work? The elements discussed can be combined in a simple model, as shown in Figure 3.3. On the left-hand side of the model are the four macro-determinants which are assumed to determine the quality of working life. In the centre are the four aspects or elements of the quality of working life discussed above. On the right-hand side are seven indicators of health and well-being which are often used. In the lower part of the model are three aspects of work capacity or coping ability, and three determinants of coping ability.

30

Figure 3.3

Model of Working Life, Health and Work Capacity

macro-determinants of the quality of working life

quality of working life

health and well-being

- economics - technology - policy -health - provison for working people

- job content - working conditions - labour relations - employment attitude

- illnesses - death - complaints - visits to physician - sickness absence - employment disability

- ^

- demography - education - social and cultural developments macro- determinants of wor Ic capacity

—•

^

W

-age - sex - education

indicators of work capacity

The arrows show the supposed directions of causality. Little further explanation is required, though something should be said about the indicators of (physical and mental) work capacity. Depending on age, sex and education, certain stressors may or may not affect health. For instance, young people are generally capable of lifting and carrying greater weights than their elders, and people with a high level of education are likely to be more resilient to certain mental stressors and to have more coping abilities at their disposal than those less well educated. The model described above can serve the reader as a guide to the rest of this book. There is no intention, however, of attempting to verify the model with empirical material. The block 'macro-determinants of the quality of working life' is discussed in Chapter 4, the block 'quality of working life' in Chapter 5, the blocks 'macro-determinants of work capacity' and 'indicators of work capacity' in Chapter 6, and finally the block 'health and well-being' in Chapter 7.

31

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THE MACRO-DETERMINANTS OF THE QUALITY OF WORKING LIFE

4.1

Introduction

In their book 'The future of work and health' Bezold et al. (1986) conclude that there are four 'key trends' (also called macro or environmental factors) that determine the future of working life: economic developments, technological developments, developments in the norms and values of people, countries and/or societies and, finally, changes in the work and the work situation itself. Bezold et al. (1986) then distinguish three key trends that determine the future of health and health care: demographic developments, changes in the financing and organization of care, and changes in attitudes towards health and health care. Bezold's key trends are employed below, although here and there the particular stress may differ. In this chapter four topics will be reviewed, namely economics (section 4.2), technology (section 4.3), health care activities (secUon 4.4) and policy directed at work and health (section 4.5). Demography and norms/values will be treated in Chapter 6 in the section about the working or coping capacity of the workforce. 4.2

The economy as a determinant of the quality of working life

The assumption here is that in an economic boom the corporate sector and institutions wiU invest not only in buildings, machines and materials, but also in a better quality of working life. The latter may be prompted only by the wish to remain competitive in the labour market, in that good staff can be lured by the good working conditions. Figure 4.1 shows changes in the rate of unemployment rate (as an indicator of the economy) in the Netherlands since the 1950s.

33

Figure 4.1

Unemployment in the Netherlands (1952-1990) (in percentages of the working population). Source: CBS

percentage unemployed

The rate of unemployment was relatively stable until the early 1970s. Thereafter there was a steady rise, reaching a peak in 1983-1984. From these figures it may be concluded that the economic situation in the Netherlands in the 1980s did not favour investment in the quality of working life. Since the beginning of the century (see Figure 4.2), there have been important shifts in the structure of employment. Employment in agriculture fell continuously - from 30% to 5% of the total working population - while employment in industry began to fall in the second half of the 1960s. Employment in the service industries steadily increased in the period 1899-1987, especially since 1971, while employment in the building industry has remained relatively constant, accounting for 6-8% of the working population. From these trends it may be tentatively concluded that the quality of working life has improved in the last decades.

34

Figure 4.2

Percentage of the working population in four branches of industry (1899 - 1987). Source: CBS, 1989

percentage of the total working population

1899

4.3

1909

1920

1930

1947

1960

1971

Agrjc. & fisheries

—^ Manufacturing ind.

Construction ind.

-3-

1981

1987

Services

Technology as a determinant

As in the case of the economy, the assumption here is that technological developments (i.e. developments in production techniques in industry and administration) can have both positive and negative effects on the quality of working life. Experts still disagree about the nature of these effects (see for example, Huijgen, 1989). Technology is concerned with the way a firm or institution operates. One can talk about industrial technology, training technology, insurance technology, transport technology, agricultural technology, etc. Most studies and publications refer to production technology in manufacturing. Woodward (1965) distinguished three types: process-production (of, for example, rubber or oil), mass-production or production of large batches (of, for example, cigars) and unit-production (as with aeroplanes). Woodward established that each of these three types of production technology went together with a specific pattern of management and organization.

35

Mass-production often involves short-cycled work (for example, in food, tobacco, timber, furniture and metal industries). Brouwers et al. (1988) estimate that 5% of the Dutch working population carry out short-cycled work (with short cycles of no more than one and a half minutes). The authors do not expect automation to replace short-cycled work in the future, but expect, for example, that 'operator-functions' will be created in which short-cycled work will take place. Developments in computer and communication technology in the industrial and administrative environment are discussed below. In the industrial automation of batch production (as, for example, in the metal and electrotechnical industries), technological development is characterised by the application of computer-aided design, computer-aided processing machinery (CNC) and industrial robots (for welding, spraying, painting, grinding and loading). The number of industrial robots has increased greatly since the beginning of the 1908s, both in the Netherlands and elsewhere. In the Netherlands the number rose from 40 to nearly 800 in the period 19821989. Almost a quarter of the robots are to be found at the sole car manufacturer in the Netherlands. The most important use of robots is in welding. In comparison with other countries, the spread of robots has been hmited. In the process industry the most important technological development has been the control technology applied to the production process. In the early 1950s computer and communication technology was introduced into the administrative sector. Large administrative processes are now automated, and many routine operations formerly done by people are performed by machines. Around 1970 developments in the computer and communication industry gave rise to what is now termed information technology. Figure 4.3 shows the increase in the number of computers, terminals and word processors during the period 1979-1989 in the Netherlands. According to the automation statistics of the Central Bureau of Statistics, there were around 240,000 computers in use in the private sector in the Netherlands in 1988 and around 250,000 in the government sector, each with a minimal purchase value of 2,0(X) guilders (approximately US $1,000). Word processing hardware and computers for industrial automation (e.g. hardware for computer-aided design, computer-aided manufacturing) were not included in those figures.

36

Figure 4.3

Growth in the number of computers, terminals and word processors, 1979-1989, in the private sector in the Netherlands (1987=100). Source: CBS, 1985 - 1989

computers 11979

^^1981

terminals [II]l983

^1985

word processors (10101987

^1989

The degree of automation was not evenly spread throughout the various branches of industry in 1986; the figures show for instance that trade and service industries had a higher than average degree of automation, while the building industry had the lowest. The use of computers and telecommunication makes the place where and the time when work is carried out relatively unimportant. One of the consequences of this is so-called telework. Geographical divisions between firm and employees can be bridged by telecommunication and microelectronics. Most telework, like traditional home-based work, is carried out by women, and offers a quality of working life that is not optimal. The work is mainly administrative: inputting data, typing and processing reports on a word processor. There are some highly skilled teleworkers, such as programmers, project managers and computer analysts and these are mostly men. The leading employers of teleworkers are those involved in banking, insurance services, the computer and software industry and the graphic industry. It is estimated that, given the present state of technology, 2 million out of a workforce of 6.5 million would potentially be employed

37

as teleworkers in the Netherlands. In the mid-1980s there were only a few hundred (Weijers & Weijers, 1986). Koopman and Algera (1989) studied the effects of automation on employment and the quality of working life. They conclude that in both cases experts' forecasts differ widely. With regard to the quality of working life, they quote research that suggests that automation has a positive influence on working conditions. There is less optimism about job content. Some authors foresee a polarization in labour qualifications. 'On the one hand, a relatively small elite of specialists will emerge who will be forced to increase their knowledge continually, while on the other a large number of routine tasks will be carried out by semi-skilled people who have little knowledge of the systems with which they work.' (Koopman & Algera, 1989). They add: 'Automation can have both a positive effect (the elimination of dirty and dangerous work through remote control) and a negative one (the erosion of tasks through the integration of decisions in the software programmes).' The consequences of working with display screens have been researched by Pot et al. (1986). They conclude that continuous work with display screens (in combination with high pressure of work) can lead to headaches, stress, back trouble and fatigue. Finally a few words about chemical or process technology. In 1987 there were more than 100,000 chemical substances on the market in the EEC. According to the criteria of the Hazardous Substances Directive, it is estimated that at least 20,000 substances are a danger to health. Approximately 700 substances in the Netherlands have a Maximum Accepted Concentration in the air, a limit value set by the government. A large amount of empirical material has been collected about different forms of technology in the last decades. From this two main conclusions can be drawn about the quality of working life: (a) Physical demands will drop through the mechanization and automation of industrial processes, but mental demands may increase, for example through task erosion. (b) the automation of administrative production processes will lead to a reduction in routine administrative work and to an increase in work with display screens, which will make heavy mental demands for prolonged periods of time. 38

4.4

Occupational health care as a determinant

The reason for including occupational health care among the determinants for the quality of work is that this type of care aims to improve the quality of working life, as well as helping individual employees who have suffered illnesses or accidents. It needs to be understood that occupational health care practitioners have an advisory function and no line responsibility for the quality of working life, a fact which limits their influence. Some facts and figures on Occupational Health Care (OHC) in the Netherlands will be given here. It should be borne in mind that the working population in the Netherlands consists of some 6.5 million people out of a total population of 15 million people (see also Chapter 6). The scope of OHC is shown in Table 4.1.

Table 4.1

Number of occupational health services, organizations served and workers covered, by three types of services in the Netherlands in 1989

Type of occupational health services

Number of occupational health services

Joint OHS (privately organized)

49

4,000

950,000

Single OHS (privately organized)

70

155

525,000

OHS departments (of public agencies)

66

3,300

550,000

185

7.455

2,025,000

All

Organizations served

Workers served

Three types of services are distinguished. Joint services (BGDs) are nonprofit making bodies, working for a number of enterprises at once and administered by management and labour representatives from these firms. 39

Each service has its own management. In 1989 there were 49 of these services, offering care to some 4,000 firms with a total of nearly 1 million employees. Single services are founded by one firm and work for that firm only. There were 70 of these services in 1989 serving 155 companies and over half a million employees. A third type of service is formed by OHC departments of the central government and local authorities, delivering care to their own staff. Nearly all of these services are joint in the sense mentioned before. There were 66 such services, serving some 3,300 organizations/agencies and over half a million employees. In total, therefore, more than 2 million employees are served (30-35% of the Dutch work force). All care is paid for by employers. The care required is laid down in the Health and Safety at Work Act. If a firm is mainly of an industrial nature and has more than 500 employees (or bears some specific risks such as the handling of lead), OHC is compulsory under the Health and Safety at Work Act. The firm is obliged to found its own single OHS or engage an existing joint OHS. The OHC given to that firm must be certified by the Labour Inspectorate. In other cases OHC is voluntary. Where care is compulsory the Act specifies 22 tasks that a service must perform. The main tasks are: - medical examinations when workers are recruited - periodic medical examinations of workers exposed to certain risks - to stay informed of the conditions of work and to advise on these - to provide first aid (treatment other than first aid is not allowed in principle) - to report suspected cases of occupational disease - to help restrict sickness absence. Certification of sickness absence can be done by the OHS. In the private sector, certification is usually done by the Industrial Insurance Board of the industry in quesfion. In some large firms, however, certification is delegated to the occupational health service. The certification is done by the occupational physician himself or by a specially appointed physician in the service. In the public sector, certification of sickness absence of all civil servants is a task solely for the occupational doctor.

40

Figure 4.4 shows the increase in the extent of occupational health care in the Netherlands in the period 1973-1988. While there was only a small increase in the number of occupational health services, from 151 to 173, the number of occupational health physicians nearly doubled from 514 to 981. Approximately 80% of them work full-time. The number of occupational health nurses increased from 435 to 532, and the number of employees who have access to occupational health care increased from about 1 million to about 2 million in the period 1973-1988. Figure 4.4 Number of occupational health care services, physicians, nurses and other staff in the Netherlands (1973-1988). Source: Jonkers and Lindeman-Clocquet, 1989

physicians

services

Il973

ESl976

[ZIil979

employees (x 10000)

11962

GII0]l985

^^1988

The degree of occupational health care is highest in the building industry, where 100% of employees have access; for industry as a whole the figure is 40% and in services it is approximately 30%. Not only physicians and nurses but other staff, such as occupational hygienists, work in the occupational health services. In the study by Meerman and Middendorp (1990) an overview is given of the staff categories responsible for the 'well-being problem' at work (in the interpretation of the Dutch Health and Safety at Work Act). In half the 41

cases this turns out to be the concern of personnel staff. The remainder are members of special commissions, line managers, company and organization consultants and (to a small extent) occupational health physicians. Around 100 full-time and 150 part-time occupational therapists are also employed in companies and institutions in the Netherlands (estimate by the professional association of occupational therapists) and some 1,400 safety experts (estimate by the professional association). Finally it should be mentioned that there are some 1,000 insurance doctors who are consulted about the Sickness Benefit and Disability Insurance Acts. At present advising fimis and institutions on the quality of working life is a marginal activity for this professional group. The future integration with occupational health care is advocated by many insurance physicians, as the relationship between insurance doctors and the quality of working life would then become clearer. In conclusion it can be said that occupational health care is available to only one third of the working population of the Netherlands, mainly employees of large and well equipped firms. There is, however, a slow but steady increase in this type of health provision. 4.5

Dutch government policy as a determinant of working conditions

It goes without saying that the policies of governmental authorities, employers and employees can play a role in improving the quality of working life in factories and offices. Although employers' and employees' organizations have for many years regularly given their opinions about questions of work and health, we feel that to report and analyse these opinions here would be going beyond the scope of this overview. We shall therefore limit ourselves to developments in domestic legislation which, while formulated by many sections of society, is heavily influenced by employers and employees. Social and technological reform and innovation in the 1970s brought about much criticism of the laws which regulate the protection of work. The following three elements played an especially important role:

42

- nationally and internationally more attention was paid to the quality of working life and to safety, health and well-being; - the right of worker participation received social acceptance; - sickness absence and employment disability, as well as the costs of the benefits, increased steadily during the 1970s. This led to the insight that completely new legislation was needed for the protection of work. The Health and Safety at Work Act came into force in November 1980. The main points of this new Act are as follows: - the law assumes a different relationship between government and industry and sets up rules which are directed less to health policies and more to the organization of the firm (e.g. structures for the consultation between the different parties). - the law compels the employer to carry out measures with respect to safety, health and well-being, which must be integrated into the general policies of the company. - the purpose is to let the employee share responsibility for company policy with respect to the quality of working life by improving mutual consultation. - the concept of well-being has been incorporated in the law as the key concept for the humanizing of working life. This is worked out in such (objective) aspects as: (1) the work situation must be ergonomically suited to the individual characteristics of the employee, (2) work must contribute to the professional competence of the employee, (3) there must be room for manoeuvre in the execution of the task, as well as (4) the possibility for social and functional contacts with others and (5) for information about the purpose and products of the work, together with the demands involved, while (6) short-cycled work and a work pace which has been set by a machine need to be avoided or interspersed with periods of rest or other work. - the policies and the powers of the Labour Inspectorate must be adapted to the new law. The Inspectorate now has the power to issue a ruling. This is intended as a coercive measure to be used when job consultation within a firm has come to a standstill. At the same time the way the Inspectorate relates to the representatives of employees has been revised. As a result a member of the Works Council has the right to accompany the Inspector on his round of the firm and to speak to him privately. The Labour Inspector is legally bound to report to the Works Council all the information given to the employer. The Council in turn has the right to ask further questions related to this.

43

- under the Act firms are now required to appoint a safety team or safety expert, in order to build up expertise in this area. The Health and Safety at Work Act came into force in all its component parts in 1990. After the first phase of the law was introduced, the Ministry of Social Affairs commissioned an evaluation study. This study examined the extent to which the new law had promoted attention to working conditions in companies (Reubsaet et al., 1988). Some results of this study are given below: - the Health and Safety at Work Act has encouraged improvements in working conditions. - working conditions are a contentious issue in only a few companies. Many managing boards and works councils have delegated their tasks in the area of working conditions. - in many firms the responsibility for working conditions appears to lie formally or informally - with middle management. The way middle management carries out these responsibilities is not, however, entirely satisfactory. The underlying problems are an insufficient familiarity with the law, a shortage of specific training, lack of insight into the cost-benefit relation of working conditions and an absence of the necessary resources and powers to carry out the tasks of the Health and Safety at Work Act. - the role played by other employees in the introduction of the Health and Safety at Work Act has been small. The factors responsible are a lack of knowledge of the Health and Safety at Work Act and its consequences, combined with and a lack of interest in the subject of working conditions. - Safety officers are instrumental in structuring (and stimulating attention in) working conditions. - the Occupational Health Services do not appear to be greatly involved in the improvement of working conditions, and in most companies have no policy influence. A number of laws apart from the Health and Safety at Work Act affect working conditions and the quality of working life. One of these is the first Works Councils Act, which came into force in 1950. Since then the scope of this law has repeatedly been extended. At the present moment it is compulsory for companies with 35 or more employees to set up a Works Council. Companies with 10-35 employees are not compelled to do so, but the law does provide for a limited participation on the part of all

44

employees. The participation of employees in a firm with fewer than 10 employees is not regulated by law. The Sickness Benefit and Disability Insurance Acts and the way in which these two Acts are applied have a great influence on the extent of sickness absence and employment disability in the Netherlands, and so are relevant to the discussion of working conditions. In his international comparison Prins (1990) came to the conclusion that rules and procedures concerning illness and employment disability are not only more liberal in the Netherlands, but are applied more flexibly than in Belgium or Germany. Comments on the two Acts vary. On the one hand, it is said that they allow employees to recover fully from illness or accident because they do not have to work while unwell. On the other hand, it is pointed out that these two Acts do not encourage employers to carry out active policies concerning work and health, sickness absence and employment disability: nor do they encourage employees to carry on working or return to work quickly in situations where this would be possible. In 1990 the Government initiated a public debate to review the Sickness Benefit and Disability Insurance regulations. At the heart of the debate was the question of whether the responsibility for financial risks should be shouldered directly by employers and employees. 4.6

Summary and conclusions

In this chapter four (external) determinants of the quality of working life have been discussed. The first of these concerned the economy. We saw that the economy was relatively healthy in the 1950s and 1960s. In the 1970s it deteriorated, reaching its lowest point at the beginning of the 1980s, with numerous bankruptcies and high unemployment. Since that time the economy has been recovering, and investment has increased not only in buildings, machines and materials, but also in the quality of working life. This recovery has coincided with a large increase in the number of people working in the service industries and a corresponding decrease in the number working in manufacturing, construction and agriculture. The second determinant of the quality of working life was technology. Two conclusions may be drawn with respect to the impact of technological developments on the quality of working life in firms and offices: 45

(a)

(b)

through the mechanization and automation of industrial production processes (manufacturing and assembly), the physical workload will on average have lessened, although the mental load may well have increased in certain occupations; Through the automation of administrative production processes routine administrative work will be reduced and working with display screens will increase, possibly making heavy mental demands on those performing such work for extended periods of time.

The third factor discussed was occupational health care. We found that the following groups of professionals are concerned with the care and advising of people in employment: personnel managers (in terms of the Health and Safety at Work Act they can be better described as 'well-being experts'), occupational therapists, occupational health physicians, safety officers and insurance company doctors. Employees in the Netherlands who are faced with problems in the area of (mental) health and well-being usually have to deal with personnel managers in terms of receiving care. Occupational health care is limited to one third of the working population, mainly employees of the larger, better equipped firms, although there has been a gradual expansion in occupational health care in the 1970s and 1980s. The fourth determinant of the quality of working life considered was government policy. Central to this is the Dutch Health and Safety at Work Act, which was passed in 1980 but only came into force in all its component parts in 1990. From evaluadon studies it appears that the Dutch Health and Safety at Work Act has brought about an improvement in working conditions. A second important point of policy is concerned with the legisladon on sickness benefits and employment disability. Both acts have been under attack for many years, because many consider that the regulations and administrative procedures provide too few incentives for limiting sickness absence and employment disability in the Netheriands. At the end of the 1980s/eariy 1990s a growing consensus for change in these areas appears to be emerging.

46

5

THE QUALITY OF WORKING LIFE IN THE NETHERLANDS

5.1

Introduction

The quality of working life in the Netherlands can - as was said in section 3.3 - be divided into four main dimensions, namely the job content, working conditions, labour relations and employment conditions. These four dimensions may be further subdivided into a number of concrete aspects of the work situation that can affect health both physically and psychologically. In this chapter each of these four dimensions will be discussed in a separate section, in which the concrete aspects relating to each particular dimension will be described. The following points will be looked at for each aspect: (1) the developments in its occurrence, (2) its occurrence in the Dutch working population by industrial branch, age and sex, and (3) the health risks established in research. Apart from a large amount of quantitative material from the research literature, the main source for this chapter is the Life Situation Survey of the Central Bureau of Statistics (CBSA-SS). Table 5.1 shows the size of each sample from 1974 until 1986 and the number of working people between the age of 18 and 65 included in each sample. All the data presented relate, of course, to the employed people in the survey. The Life Situation Survey for 1989 has been published in the meantime, but it was not possible to adapt these data to the form required for this report, for which reason the time-series cover the 1974-1986 period only. It should be noted that in this chapter, as well as in Chapter 7, conclusions will be drawn about differences between time periods and differences between groups of working people. In research such differences are usually tested for significance. This is discussed in detail in the article by Bloemhoff and Smulders (1991). As a general rule a difference of 3-4% between the groups studied here can be considered significant (with a 5% probability). 47

Table 5.1

Size of samples in Life Situation Surveys for 1974, 1977, 1980, 1983 and 1986

year of survey

size of total sample (LSS)

size of sample for analysis (working; 18-65 years)

percentage

1974 1977 1980 1983 1986

4806 4159 2865 3987 4040

2376 1973 1556 1995 1897

49 47 54 50 47

Total

19857

9797

49

Readers may ask why the observed differences have not been 'controlled' for cross-cutting variables such as age and sex. In principle this would have been possible. We decided, however, not to make such corrections, as we were chiefly interested in finding out the real, 'rough' and uncorrected differences in time or between the numbers of working people in the different categories. For example if we wish to show the differences in the quality of working life between the construction industry and service industries it may be noted that in the construction industry a lot of men and in service industries a lot of women are employed. If the data were to be controlled for this or 'standardized', the results obtained would then be free of possible gender effects. In the comparison with service industries, the many men in the construction industry (with their physically heavy workload) would be weighted in the same way as the few women in that industry (with their light administrative work). The same would be true of men and women in the service industries. This did not strike us as a sensible way of making comparisons. In this and later chapters the term 'potential working population' will occur many times. It should be pointed out that this category consists of the working population and unemployed people who are officially registered as looking for work. The category 'working population' consists entirely of people who are actually in employment and therefore excludes those who are looking for work. 48

Table 5.2

Percentage of working people with complaints about aspects of work in the period 1974 - 1986. Source: CBS/LSS

1974

1977

1980

1983

1986

carrying out a lot of monotonous work

_

14

13

13

12

actual work not properly related to training and experience

.

.

28

33

34

working at a high pace

-

38

36

42

47

carrying out a lot of heavy physical work

-

20

21

22

24

working in a noisy environment

26

-

24

23

22

carrying out dirty work

28

-

28

26

25

sometimes carrying out dangerous work

-

11

10

9

8

no good prospects of advancement

-

-

68

74

70

working shifts

9

10

9

11

10

'-' : no data available

5.2

Job content

5.2.1 Monotonous work/short-cycled work In Table 5.2 (which uses data from the Life Situation Surveys of the CBS), we see that complaints about monotonous work fell slightly from 1974 to 1986. In 1977 14% carried out monotonous work, but in 1986 this was 12%. Monotonous work was most frequent in the transport sector 49

(22%) and in manufacturing as a whole (18%). Monotonous work was also carried out more often by women and young people than by men and older workers (see Figure 5.1).

Figure 5.1

Carrying out a lot of monotonous work: differences between industrial branches, men and women and age categories (n=5757). Source: CBS/LSS, 1977, 1983 and 1986 (aggregated)

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-64 36-64 >• 66 >" 66

years years years years years years

total working population. 10 20 30 40 60 60 70 percentage of affirmative answers

80

Short-cycled work, characterised by repetitive, monotonous and routine tasks which are carried out in a very short period of time and are bound by place and time, is considered to lead to stress reactions. An important factor favourable to health is autonomy or the extent to which a person is free to use his own judgement in carrying out his work (Karasek & Theorell, 1990). Links have been established between job content and sickness absence. Variety in the work situation, a high measure of autonomy and responsibility and a high degree of training go together with a low level of sickness absence (Smulders, 1984).

50

Because of new technologies the area of application for short-cycled work has been extended from manufacturing to the services (offices, laboratories). It is expected that under the influence of new technologies shortcycled work will diminish but remain as a left-over function (e.g. packaging) or take on a more intensive, but simpler form. At the same time new functions arise, the so-called operator functions, some of which are monotonous (Brouwers et al., 1988). 5.22 Training and experience in relation to actual job content Table 5.2 shows that the percentage of working people who said that their work was not properly related to their education or past experience rose from 28% in 1980 to 34% in 1986. The transport sector had the greatest negative score on that point, and agriculture the least. Here again, as with monotonous work, women and young people form a risk-group (see Figure 5.2). Figure 5.2

Actual work is not properly related to level of training/ experience: differences between branches of industry, men and women and age categories (n=3826). Source: CBS/LSS, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-54 >• 66 >• 65

years years years years years years

total working population 10 20 30, 40 60 60 70 percentage of affirmative answers

51

The discrepancy between the level of work and the level of education has been studied for the wage-earning working population in the period 1960 1985 (Huijgen, 1989). The quality of working life, measured by the level of skill required, improved in the period 1960 -1985. The increase in the level of skill required, however, was not enough to compensate for the strong rise in the educational level of the Dutch working population. One can conclude that for the period 1960 - 1985 the discrepancy between level of education (training) and level of appointment has increased for the wage-earning population. The opportunities for women are clearly worse than those for men. 5.2.3 Work pace In the CBS Life Situation Surveys (see Table 5.2) 38% of employees in 1977 declared that they had to work at a high pace, while in 1986 this figure had risen to 47%. This is one of the most striking trends in the quality of working life in the past two decades. The work pace is highest in the transport sector (48% affirmative) and in services (44%). It is lowest in manufacturing, according to the employees who work there (37%). Men and women differ little in their perception of the work pace. Young people most frequently report that they have to work at a high pace (Figure 5.3). 5.3

Working conditions

5.3.1 Heavy physical work There are few reliable statistics on trends in working conditions. For a number of working conditions estimates can be made; for others only broad qualitative statements can be made or trends indicated on the basis of subjective statements from the working population. According to the three-yearly surveys of the CBS (see Table 5.2), the percentage of working people who stated that they had to carry out heavy physical work increased slightly, from 20% to 24% between 1977 and 1986. It is no surprise that the heaviest work was in agriculture and in the construction industry, and that young men did a lot of heavy physical work (see Figure 5.4).

52

Figure 5.3

Working at a high pace: differences between branches of industry, men and women and age categories (n=5742). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >• 66

years years years years years years

I

total working population P 10 20 30 40 60 60 70 percentage of affirmative answers

Figure 5.4

Carrying out a lot of heavy physical work: differences between branches of industry, men and women and age categories (n=5758). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >" 66

years years years years years years

total working population 10 20 30 40 60 60 70 percentage of affirmative answers

53

It is clear that heavy physical work has diminished since World War II as a result of mechanisation and automation in manufacturing, agriculture and horticulture. There does however appear to have been a shift from a dynamic to a more static form of work, while work pressure and work pace have increased (Den Dekker, 1988). Heavy physical work, i.e. work where a lot of physical exertion is demanded and/or where a fixed position has to be maintained for long periods of time, can lead to adverse effects on the circulatory and the musculoskeletal systems. Besides giving rise to symptoms of fatigue, heavy physical work can lead to back disorders, inflammations and the wearing down of joints (Den Dekker, 1988). In a recent survey the following risk factors for back disorders were mentioned: working in a sitting, standing, or forward leaning position, heavy physical exertion, lifting, bending over, prolonged walking, pulling and pushing. Other factors, such as vibration, long duration and fast pace of work contribute to back trouble, as do individual factors such as age, muscle weakness and earlier back complaints (Hildebrandt, 1987). Static work load is also linked to another disorder of the musculoskeletal system, namely Occupational Cervicobrachial Disorder. This disorder affects the neck, shoulders, back, arms and hands and is the result of a static load on muscles (in the neck and back), in combination with repeated movements of the hand, arm and shoulder. If pregnant women carry out heavy physical work, this may adversely affect the outcome of the pregnancy, e.g. in the form of a lower weight at birth, dysmaturity and premature birth (Slob, 1986). 5.3.2 Noise at work The percentage of people who said that they work in a noisy environment dropped from 26 to 22% during the period 1974 - 1986 (see Table 5.2). Figure 5.5 shows that the noisiest working environments are in manufacturing, agriculture and the transport sector. It appears that men and young people are more likely to work in a noisy environment than women and older workers (see Figure 5.5). Working people's perceptions of their own exposure to noise does not, however, correspond exactly with actual exposure (Van Dijk, 1984).

54

Figure 5.5 Working in a noisy environment: differences between branches of industry, men and women, age categories (n=3813). Source: CBS/LSS, 1983 and 1986 agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 36-54 >• 66 >• 66

years years years years years years

total working population! 10 20 30 40 60 60 70 percentage of affirmative answers

Statistics about trends in the actual occurrence of noise in the workplace are not available. With the help of data about the number of working people and estimates of the occurrence of noise in the various branches of industry (and assuming an equal level of exposure in all branches of industry) an overall trend can be indicated. Through shifts in the number of workers in each branch of industry, the estimated number of employees working with exposure levels of 80 dB(A) or higher fell from almost 490,000 in 1975 to 318,000 in 1984. This decrease is also due to a large reduction in the number of employees in the textile industry. In conclusion, it appears that the actual exposure to noise in manufacturing fell between 1975 and 1984 and that the perceived exposure to noise between 1974 and 1986 also fell, but less sharply. Exact data about levels of noise in each industry are not available, but some estimates have been made for manufacturing. It was estimated that 38% of employees in manufacturing work with a level of noise of more than 80 dB(A) (Passchier-Vermeer & Jurriens, 1985). The clothing and leattier industries appear to be the least noisy. The most noisy are the 55

timber and furniture industry, the various metal industries, the building materials industry and the textile industry. One of the most important consequences of exposure to noise is loss of hearing. It is accepted that regular exposure to noise of 80 dB(A) or above can lead to impaired hearing. According to the international standard ISO 1999 this possibility already exists at a level of 75 dB(A). It is estimated that in manufacturing alone 100,000 people suffer from impaired hearing as a result of working in a noisy environment. Van Dijk (1984) concluded that deafness is the most common occupational disease in the Netherlands. Exposure to noise also leads to difficulties with concentration, stress, hoarseness (due to raising the voice) and problems with balance (Van Dijk, 1984).

5.3.3

Vibration and shocks

Trends in the number of employees exposed at work to whole-body vibrations or hand-arm vibrations can be derived from the Labour Force Surveys. Oortman Gerlings et al. (1985) provide an overview for 1971 and 1981. The total number of people exposed to whole-body vibrations has fallen in the last 10 years. This decrease has mainly taken place in jobs in agriculture and manufacturing. The number of people exposed to wholebody vibrations in administrative functions and in jobs in the transport sector has increased slightly. The number of employees exposed to handarm vibrations has also fallen in this period. A large number of employees are exposed to whole-body vibrations at work: 4(X),000 who drive vehicles for a living and 75,000 who work in manufacturing. The number of employees exposed to hand-arm vibrations is smaller, i.e. about 140,000 people who work with hand tools that produce vibrations or knocks. Most of these employees work in agriculture, horticulture, manufacturing, construction or transport. Whole-body vibrations result from a weight-bearing part of the body, e.g. the feet or the seat, being subject to vibrations. In the long run exposure to whole-body vibrations can lead to complaints and disorders of the musculoskeletal system (Bongers & Boshuizen, 1990). At the same time complaints and disorders of the digestive tract, peripheral vascular system, female reproductive organs and peripheral nervous system are linked to

56

whole-body vibrations (Seidel & Heide, 1986). For these disorders, however, there are not enough data to confirm a causal relationship. Working with certain hand tools causes vibrations and shocks to move through the hand and the arm. A specific effect of these hand-arm vibrations is the syndrome called 'Vibration induced White Fingers'. Other disorders of the musculoskeletal system (especially shoulder, arm, hand and fingers) may also result (Koemeester, 1987). 5.3.4 Climate and the Sick Building Syndrome Employees who are exposed to extreme climatic influences are those working in the building industry and agriculture (outdoor work), the metal and glass industry (extreme heat), shops and public transport (draughts), and those whose jobs involve ovens (heat), cold storage (cold), or abattoirs (damp conditions) (Zielhuis & Van Dijk, 1989). The total number of these employees is unknown. We assume that the number has decreased in recent years with automation, mechanization and the drop of employment in agriculture. Demanding climatic influences can lead to respiratory and musculoskeletal disorders. This may in turn lead to undue strain on the cardio-vascular system (Zielhuis & Van Dijk, 1989). Another health effect related to climate is the so-called Sick Building (Syndrome, a complex of non-specific complaints such as complaints of the nose, eye, respiratory mucous membranes and skin, apathy, headaches and asthma-like symptoms) which affects workers in (new) office buildings. The causes of this set of complaints are not yet fiiUy clear. The number of office buildings responsible for the Sick Building Syndrome has increased in the past 10 to 15 years. Possible reasons are the increased use of VDUs, laser printers and copying machines, more mechanical ventilation, and an increase in work pace. It may also partly be explained by an increased interest in the problem. There are estimated to be around 2 million office workers in the Netherlands, of whom approximately half have complaints occasionally and around 40,000 regularly. It is expected that the Sick Building Syndrome will continue to demand attention in the coming years (Schalkoort, 1988). 57

5.3.5 Radiation Around 0.5% of the workforce (23,000 workers) run the risk of being exposed to ionizing radiation. Those who are most at risk are employees in hospitals, nuclear centres and various manufacturing industries (Gezondheidsraad, 1985). People who are exposed to non-ionizing radiation are welders, employees in metal and glass foundries and people working with ozone rays, lasers and microwave ovens (Zielhuis & Van Dijk, 1989). The harmful effects of ionizing radiation include an increased likelihood of cancer and hereditary malformations. If pregnant women are exposed, there are risks for the unborn child, with the possibility of spontaneous abortion, retardation of growth, mental retardation and infantile cancer (Slob, 1986). Possible risks of non-ionizing radiation are 'welders' eyes' (UV-radiation), burning of the cornea (laser beams), cataracts (UV, infra-red), eye infection (UV) and ageing, burning and cancer of the skin (UV) (Zielhuis 8L Van Dijk, 1989). Visual display units emit electro-magnetic radiation. It has however been shown that working with VDUs carries no risk of radiation for the employee, or for possible offspring (Pot et al., 1986). Epidemiological studies and experiments carried out on animals show no evidence of the opposite (McDonald et al., 1988). 5.3.6 Chemical agents and working conditions In 1987 there were over 100,000 chemical substances on the market in the EEC. An estimated 20,000 substances are harmful to health according to governmental criteria. About 700 substances have a MAC-value (Maximum Accepted Concentration in the air, comparable with Threshold Limit Values), a limit value set by the government. As a consequence of new technologies, e.g. the long-distance handling of processes, exposure to chemicals has also diminished. Every year many new substances and applications come onto the market. By way of illustration a number of developments related to three chemical substances (organic solvents, asbestos and pesticides) of importance from the health point of view are discussed below.

58

Around the turn of the century only a dozen or so different organic solvents were widely used. Apart from being used in the rubber industry, the solvents were also used in the making of such products as glue. The discovery of all kinds of plastics gave a new impulse to the manufacturing of these materials in the period 1930-1960. The present production of organic solvents is several million tonnes per year (1978: 4.3 million ton). There are many very different materials and applications: 'surface coaters' (paint, etc.), cleaning materials, gluing materials, household and pharmaceutical products (Hogstedt and Axelson, 1986). New materials and applications are constantly being introduced onto the market. Because of their lipid-solving capacity, organic solvents can cause skin disorders and have an irritating effect on mucous membranes and respiratory organs. These solvents are also known to have effects on the nervous system. These effects can be acute, such as fainting, or chronic, such as fatigue and disorders in mental functioning (Hogstedt & Lundberg, 1992). Asbestos is used frequently as an insulating material and for the production of brake linings. Although the health risks of asbestos (mesothelioma, a form of cancer) have been known for decades (Swtiste et al., 1988), the Asbestos Decree only came into force in the Netherlands in 1978. Around that time a search began for replacement materials. Although exposure to asbestos is now strictly regulated, asbestos is still being used, for example in brake and friction materials. No complete prohibition is likely in the short term. The risks of exposure to asbestos will probably remain for a long time, for example in garages. Since 1945 the production and use of pesticides in horticulture and agriculture have greatly increased. The number of different active ingredients is also increasing as some products can no longer be used because of resistance or environmental problems. Exposure to pesticides can occur in production companies during transport and storage and during the application of pesticides in agriculture and horticulture. Professions and branches of industry where there is an increased risk of cancer as a result of working with toxic materials are listed in Saracci (1985). There are cancer risks involved in viniculture, mining, asbestos production and shipbuilding as well as in the construction, metal, chemical, gas, rubber, leather, and timber and paper industries. The health risks of chemicals at work are many. The effects can be classified into acute effects, such as poisoning, and chronic effects, such as 59

cancer, respiratory disorders and reproduction risks. The cancers that occur are those of the bladder, the prostate, the scrotum, the skin, the bone, the stomach, the liver, the nose and the lungs (Doll & Peto, 1981). 5.3.7 Biological agents and working conditions The most important biological agents that may endanger health are microorganisms (viruses, bacteria, fungi), allergens and toxic material from plants (e.g. pollen, but also wood dust or coffee beans) and allergens from animals (e.g. those present in faeces, hairs or in dust particles). These agents can cause infection, allergic reaction, poisoning or even cancer. The respiratory organs and the skin are the part of the body most seriously affected. (Dutkiewicz et al., 1988). For a long time the dangers of working with risky biological agents had been recognized only in the health care sector and in work with animals. Since the beginning of the 1960s, however, more and more biological agents have been discovered as a result of advanced immunological and microbiological research methods, and a greater proportion of the working population has become exposed to the dangers. The working population potentially at risk in the Netherlands is made up of employees in the food, tobacco, animal foodstuffs, meat processing, textile, leather, timber and paper industries, in agriculture, forestry, horticulture, fishing, veterinary services, health care, biotechnology, mining and catering (Dutkiewicz et al., 1988). In the health care sector, the infection risks that have had the most attention in the past years are viral infections with Hepatitis-B, AIDS, cytomegalio virus and a number of bacterial infections (Smulders et al., 1985). The infection risks at work are a hundred times smaller for AIDS patients than Hepatitis-B patients. Measures taken for the prevention of AIDS infection are sufficient to prevent infection by HIV, the virus responsible for AIDS (Rijssen-Moll et al., 1988). Exposure of pregnant women to biological agents, especially the infectious agents, can lead to an increased health risk for the unborn child (Slob, 1986).

60

5.3.8 Dirty work 'Dirty work' is a layman's term for work that involves exposure to dangerous substances - including chemical and biological exposure. But 'dirty work' may also have a connotation of 'unpleasant work', without a direct adverse health effect.

Figure 5.6

Carrying out dirty work: differences between branches of industry, men and women and age categories (n= 3828). Source: CBS/LSS, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >• 66

years years years years years years

total working population 10 20 30 40 50 60 70 80 percentage of affirmative answers

There was a slight decrease in the amount of dirty work performed in the period 1973 - 1986 (see Table 5.2). In 1974 and 1980 28% of the workforce performed dirty work; in 1986 this was 25%. Older workers do less dirty work than younger workers (see Figure 5.6). It occurs mainly in agriculture and fisheries, the construction industry and in manufacturing. One third of working men and one tenth of working women report that they carry out dirty work, i.e. work which involves getting dirty hands, clothes or hair or inhaling 'dirty substances'.

61

5,3,9 Unsafe working conditions/dangerous work A description of occupational accidents in the Netherlands will be provided in Chapter 7 (section 7.7). In that section health effects are the subject, whereas in this section the causes will be discussed: unsafe and dangerous working conditions. The percentage of working people in the Netherlands who state that they carry out dangerous work fell slightly in the period 1977-1986, from 11% to 8% (see Table 5.2). In the construction industry and in the transport, storage and communications industry, between one fifth and one third of employees state that they carry out dangerous work (see Figure 5.7). Figure 5.7

Carrying out dangerous work occasionally: differences between branches of industry, men and women and age categories (n=5754). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-54 36-64 >• 56 >• 56

years years years years years years

total working population

10 20 30 40 60 60 70 percentage of affirmative answers

80

Around 10% of working men and 4% of working women state that they sometimes have to carry out dangerous work. Older workers carry out dangerous work less often than younger people (see also Figure 5.7). No overview of unsafe working conditions exists. In order to arrive at an inventory of unsafe work situations, use can be made of the classification 62

of causes of accidents as registered in the accident records of the Netherlands' Central Bureau of Statistics (CBS, 1972-1991): mechanical objects in operation (e.g. tools and machines) and not in operation (e.g. ladders, falling objects), thermal contacts and radiation, chemicals, living agents, excessive load of parts of the body and traffic accidents. Mechanical objects cause around 93% of accidents at work. Accidents due to mechanical objects not in operation (e.g. falling objects) occur often in the construction industry and in agriculture and fisheries. Objects working functionally (tools, machines) cause a lot of accidents, especially in manufacturing and in agriculture and fisheries. Accidents due to thermal contact and radiation (e.g. welding tools, hot water) occur most often in the construction industry and in manufacturing. 5.4

Labour relations

The most commonly used indicators of labour relations are relations between employees and management, relations between colleagues, possibilities for consultation, participation, and management style. Relations with clients do not fall under the heading of labour relations but under aspects of job content. From a comparison of a few company characteristics of 85 comparable production companies in 1964/1965 and 1980/1981, it is evident that a number of changes took place in labour relations in that period: more delegation of responsibilities, less authoritative management of companies and more professional support of personnel (Smulders, 1984). On the other hand, research on the impact of micro-electronics in the service industries indicates that new - often not transparent - possibilities for supervising employees are made available by automation (Weggelaar & De Boer, 1984). Social relations (between colleagues and between different levels of the internal hierarchy of a firm) can lead to stress if the demands from the social environment cannot be satisfied or if the number of social contacts do not meet the expectations, needs and norms of the employee. Good social relations appear to correlate with job satisfaction and general well-being and poor social relations with complaints of a psychological 63

nature (Karasek & Theorell, 1990) and with sickness absence (Smulders, 1984). Social relations can also ease stress due to other causes: this has been coined social support in the literature on stress. Strong, personally experienced social support from the boss or colleagues goes together with greater job satisfaction, fewer complaints of a psychological nature and less concern about one's own functioning. Social isolation can therefore be considered a stress-inducing factor at work. Social isolation can occur when the work site is isolated, as with home-based work, or when communication is impeded by physical circumstances, as with noise (Karasek & Theorell, 1990). 5.5

Employment conditions

Employment conditions can be characterised as: pay, pension, working hours, education possibilities, job security, promotion prospects, child daycare facihties, personnel management and occupational health care. Empirical data on these aspects are very scarce in the Netherlands. In this section we shall therefore only discuss a few aspects. 5.5.1 Promotion possibilities/prospects Data from the Life Situation Survey of the CBS give an insight into how some career aspects are experienced by the working population in the Netherlands. Opinion about promotion possibilities has not changed much in the last few years: in 1980 68% of the working population were unsatisfied with promotion possibilities; the figure had risen to 70% by 1986 (see Table 5.2). As far as differences between particular branches of industry are concerned, opinions about promotion possibilities are most negative among people working in agriculture and in the construction industry, and most positive among those working in transport and in manufacturing (see Table 5.8).

64

Finally it can be seen in Figure 5.8 that women and older employees are more negative about their promotion possibilities than men and younger workers.

Figure 5.8

Absence of good promotion possibilities at work: differences between branches of industry, men and women and age categories (n=3681). Source: CBS/LSS, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >• 66

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

85

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ 69

1 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

^^^B

67

72

years years years years years years

totai worldng population

^ 10 20 30 40 50 60 70 80 90 100 percentage of affirmative answers

When promotion possibilities do not coincide with the needs, norms and expectations of employees, dissatisfaction at work results. It appears from many studies that satisfaction about promotion possibilities goes together with a low level of sickness absence. A more important employment condition, in relation to stress, is job security. Lack of clarity and uncertainty about the future (due to reorganizations, mergers, changes in job content due to automation) can give people the feeling that they no longer have the situation in their own hands. This is seen as a major cause of stress (Karasek & Theorell, 1990).

65

5.5^ Length of working hours The average number of working hours in the Netherlands has fallen by 50% in the last 80 years, from 60 hours per week in 1910 to 40 hours per week in 1987 (see Figure 5.9). Between 1910 and 1945 there was a sharp fall in the average number of working hours per week. After 1945 the average number of hours worked fell more gradually, but the number of working days decreased and part-time work increased, particularly in the last decade (De Neubourg & Kok, 1984). In 1971 11% of the total labour force worked for less than 35 hours per week. This percentage almost trebled over the next 16 years to 31% in 1987 (CBS/Labour Force Surveys). The number of holidays and other days off increased five-fold between 1910 and 1987 (from 8 to 44 days per year) in the Netherlands (see Figure 5.9).

Figure 5.9

1910

Development in the number of working hours per week and the number of holidays and other days off, per year (1910-1987). Number of working hours: average of adult employees in manufacturing, excluding overtime. Source: CBS, 1989

1960

1960

- * - working hours/week

66

1970

1980

- ^ days of vacation/yr

1987

In 1971 31% of women worked part-time (less than 35 hours per week), while in 1987 more than 60% of women did so. The number of men working part-time also increased over this period. Figure 5.10 shows that older workers are more likely to be employed part-time than younger workers, and that part-time work is most common in the service industries (25%) and least common in the construction industry (3%). Figure 5.10 Part-time work (less than 35 hours per week): differences between branches of industry, men and women and age categories (n=5721). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-64 >• 66 >• 66

years years years years years years

25

62

total working population 10 20 30 40 60 60 70 percentage of affirmative answers

80

Finally a few words about the effects of shorter working hours on health indicators. As part-time employees work fewer hours than 'normal', their workload is on the whole less and there is more spare time in which to recover. Research on differences in sickness absence between full-time and part-time workers does not confirm this: the way in which spare time is used is the important factor (Vrijhof, 1985). Furthermore part-time workers sometimes decide to work fewer hours because of health problems, which will change the relationship between the number of working hours and sickness absence. 67

5.5.3 New work patterns/work contracts As the working week becomes shorter interest in the 'compressed' working week (for example 36 hours in four days) becomes greater. Working hours have become ever more flexible, a trend reflected in a diversity of working patterns. The freedom of choice of employees with respect to working hours has led to more flexible labour contracts, temporary jobs, on-call contracts and home-based work. Some data on new work patterns in the Netherlands are provided below: - Around 15% of men and women under 25 have temporary jobs, while for men and women over 25 the figures are 4% and 8% respectively. In sectors such as services in old people's homes, hospitals and cleaning firms there are more part-time jobs than elsewhere (CBS/Labour Force Sample Survey, 1985). - On-call contracts are most common in the hotel and catering industry and in large shopping chains. Almost 70% of the on-call workers are married women; the rest are students, old age pensioners and unmarried women (Van Eijk & Derks, 1987). - It is estimated that at least 3% of the workforce did home-based work in 1985 (Vissers et al, 1986). The vast majority of home-based workers are women. The effects of flexible contracts on health and well-being are not clear. What is clear, however, is the lack of security that goes with these new contracts. Extreme examples are on-call contracts and home-based work. In the former case the employee has little or no say about working hours and working time, and his legal position in regard to social benefits (minimum wage, sickness and disability benefits, unemployment benefits) is weak. Home-based workers are left totally on their own; they have to organize their own working times and have no contacts with colleagues. This can lead to increasing social isolation (Van Eijk & Derks, 1987). 5.5.4 Shift work From the beginning of the 1960s to the present day there is no clear pattern to be discerned in the prevalence of shift work and irregular work in manufacturing (Jansen, 1987). In the period 1974-1986 the percentage of people doing shift work fiuctuated around 10% of the total labour force (see Table 5.2). In 1987 around 14% of men and 15% of women worked 68

irregular hours or in shifts. Men work more in shifts, women more at irregular times. Young people do a relatively large amount of shift work. Shift work is most common in manufacturing, transport, storage and communications firms. Irregular working times are found mainly in the hotel and catering sector, transport, storage and communication firms and 'other services'.

Table 5.3

Percentage of employees working at irregular times and in shifts, by branch of industry and sex in 1987. Source: CBS, 1990; salaried employees

Industrial

Percentage of employees working at irregular times

m

f

Percentage of employees working in shifts

m

Percentage of employees working at irregular times or in shifts m

f

f

Agriculture and fisheries

0

1

0

0

0

1

Mining and manufacturing industry

1

0

21

3

22

3

Public utilities

2

0

3

0

5

0

Construction industry

0

1

0

0

0

1

Retail and wholesale trade, hotels and restaurants, repair of consumer durables

1

2

1

0

2

2

36

32

45

35

Other services

10

23

0

0

10

23

All industry

7

14

7

1

14

15

Transport, storage and communications industry Banking and insurance, commercial services

69

Age is important with respect to the effects of shift work, as older people have more problems in adjusting to changes in sleeping and eating patterns. Working in shifts can lead to disturbances in sleeping patterns and eating habits. Because the 24-hour rhythm is not the normal one, disturbances can arise in the physiological functions of the body. The main health complaints related to shift work are sleeping problems, lack of appetite, chronic fatigue, disorders of the digestive and respiratory systems and cardiovascular disorders. Working in shifts also has important consequences for the social life of these workers and their families (Meijman et al., 1988, 1989). 5.6

Summary and conclusions

In this chapter some 20 key aspects related to the quality of working life were reviewed. For each of these aspects two questions were asked: what have been the developments in the recent past, and in which categories of the working force is the situation better or worse. The categories of the working force considered were branch of industry, age group and sex. The most important source of data was the Life Situation Surveys of the CBS for the years 1974-1986 (covering some 10,000 employees in total). Use was, of course, made of many other sources. First the longitudinal trends. The trends relate mostly to the 1977-1986 period because a number of data from 1974 were missing. In the case of some aspects it is not properly clear how the trends took place (e.g. radiation, chemical, climatic and biological working conditions). Favourable developments are the following. Exposure to vibrations and shocks has been reduced with time, as have dangerous work, noise, dirty work and nasty smells at work. Furthermore labour relations have improved in the last decades and working times have been shortened. Negative developments are the following: less correspondence between level of education and experience and level of skills required, a higher work pace and more heavy physical work. Finally there have been no major changes with respect to monotonous work, promotion possibilities and shift work.

70

It is important to establish next which groups are most at risk with respect to the quality of working life. Let us first look at the branches of industry. The transport sector scores negatively on many aspects. A lot of monotonous work is performed at a high pace, and there is poor agreement between the level of training/experience and the actual work done. Those working in the transport sector are exposed to considerable noise, vibration and shocks, dangerous work, shift work and long working hours. It is recommended that government, employers and employees, and those involved in health care and research, pay more attention to the transport sector than hitherto. When it comes to the branches of industry with the most groups at risk, manufacturing and construction are together in second place, after transport. In manufacturing there are many adverse diverse conditions - monotonous work, noise, vibrations/shocks, radiation, biological and chemical risks and labour relations - which could be improved. In the construction industry there are specific problems: limited possibilities for promotion, much heavy physical work, unfavourable climatic working condidons, chemical risks, unsafe and dirty work and long working hours. Agricultural workers perform a lot of heavy physical work and dirty work, are subject to biological risks and have few possibilities of promotion. Finally the service sector scores relatively favourably in almost all aspects. Most of the problems are to be found in the work pace, the mental load and the irregular working hours/shifts. It must be added, however, that the overall picture of the service sector is heavily dominated by banks and insurance companies. It should, however, be borne in mind that such categories as education, health care, police and prisons also fall under services. Let us now take a look at the differences in the work situation of men and women. Male work is characterised by a higher work pace, heavy physical work, noise, unsafe conditions and long working hours. Unfavourable aspects of female work are monotony, lack of promotion possibilities and a poor correspondence between training/experience and the actual work done.

71

Finally a few words about age categories. The conclusion - in as far as data are available - is that younger people work in much worse conditions than older workers. Younger people carry out more monotonous work and at a higher pace; their work is more physically taxing, more dangerous and is carried out in an environment with more noise. They woric more hours per week and work more in shifts. The only positive point is that younger people see more possibilities for promotion than older people - but then it would be odd if this were not the case. It is also true that many older people cannot keep up with the job and leave the labour force under the disability provisions. In other words their coping ability - most probably 'damaged' by years of work - can no longer match the workload.

72

CHARACTERISTICS OF THE WORKING POPULATION IN THE NETHERLANDS

6.1

Introduction

As explained in sections 3.4. and 3.6, we assume that the work capacity of the working population partly determines whether demanding factors at work will or will not lead to adverse health effects. Work capacity may be defined as the total physical and mental abilities of the worker in carrying out a particular task at a given moment. Physical work capacity, knowledge, skills and emotions are all contributory factors (Van Dijk et al., 1990). Important indicators of the work capacity of working people are age, sex, level of education and social and cultural norms and values in relation to work. These aspects and their development over time will be discussed in this chapter (from sections 6.3 to 6.6). But first a total picture will be given of the Dutch population and labour force in the past, present and future (section 6.2). 6.2

The population and the labour force in the Netherlands

The Dutch population has increased from 5 million at the beginning of this century to 15 million in 1990. The potential labour force (i.e. those people who are in employment together with those who are officially looking for jobs) as a proportion of the total population has decreased with respect to men and increased with respect to women (see Figure 6.1). In 1990 the total potenfial labour force came to almost 7 million people. Of these, almost 4 million men and 2.4 million women had jobs and 0.6 million people were unemployed (CBS/Labour Force Survey, 1991).

73

Figure 6.1

Trends in the Dutch male and female potential labour force (1899-1987) as a percentage of the total male and female population. Source: CBS, 1989

As a percentage of the total male and female population

||69 59

62 63 « 61

ei

il 57 fii

64

50

52

r

18 19 19 20

1899 1920 1947 1971 1987 1909 1930 1960 1981

22

1899 1920 1947 1971 1987 1909 1930 1960 1981

I women

6.3

Age

Table 6.1 shows the age development in the potential labour force in three age groups from 1899 to 1990, as weU as a forecast for 1990 to 2010. We see that in the past the proportion of young people steadily decreased and that the same pattern will hold in the future. The percentage of older people (50 and over) remains relatively stable throughout the 1899-2010 period. This percentage falls slightly in the period 1960-1988 but is expected to increase in the coming 20 years (1990-2010). Reasons for these developments are the greater participation in education of younger people and the retirement, early retirement and employment disability of the older workers. Figure 6.2 shows the expected changes in 5-year age groups for the period 1990-2010. We see a sharp decrease in the 20-34-year-old age groups and a sharp increase in the 45-64-year-old age groups. 74

Table 6.1

Trends in the potential labour force, by age and sex (1899-2010). Source: CBS, 1991; Op de Beke & Arts, 1987

25-50 year %

>50

women

men

total

year %

year %

%

%

%

34 34 34 33 29 27 28 23 20 13

45 46 47 48 50 50 51 60 66 64

21 20 19 19 21 23 21 17 14 23

23 24 23 24 24 22 26 31 39 41

77 76 77 76 76 78 74 69 61 59

100 100 100 100 100 100 100 100 100 100

<25

1899 1909 1920 1930 1947 1960 1971 1981 1990 2010

Figure 6.2

Expected changes in the percentage age distribution of the Dutch potential labour force (1990-2010). Source: Op de Beke & Arts, 1987

percentage

15-19 years

20-24 26-29 30-34 36-39 40-44 46-49 60-64 66-69 60-64 years years years years years years years years years

1990

12010

75

It is clear that Dutch industry will have a problem on its hands. In future there will be far too few young people to carry out the necessary physically demanding work, and few older people will be capable or willing to take this up. In other words: adjustments will have to be made in the work offered. 6.4

Sex

In 1899 the breakdown of the potential labour force was 77% men and 23% women (see Table 6.1). Over the years more and more women came into the labour force, so that by 1990 the percentages were 61% and 39% respectively (CBS/Labour Force Survey, 1991). The percentage of women working will continue to increase, up to 41% in 2010 (Op de Beke & Arts, 1987). The conclusion is that firms and offices will have to take 'more work for women' into account in the coming 20 years. Typically male work (physically heavy work, for instance) will be difficult to offer, while the demand for lighter work, with flexible working hours related to the demands of the family, will become greater. There is an overrepresentation of men, not only in the whole working population but also in the different industrial branches. This distribution over the branches of industry has scarcely changed in the 1971-1990 period. Men are more evenly spread over aU branches. Women, on the other hand, are concentrated in just a few industries, holding 66% and 69% (1971 and 1990 respectively) of the jobs in catering, trade and 'other services'. 'Typically' male industries are agriculture and fisheries, manufacturing, the construction industry and transport. 'Typically' female industries are retailing, catering and other services. In banks and insurance companies men and women are equally represented (9-10% respectively of the total labour force). Between 1971 and 1990 the proportion of both men and women working in manufacturing, mining and public utilities fell and the proportion in services increased. 6.5

Education

The average level of education, for both men and women, rose in the 1975-1990 period. The number of employed people with only primary 76

schooling or a low-level vocational qualification fell sharply, while the number of people with a completed secondary school education or middlelevel vocational qualifications increased. In 1975 only 25% of males had completed a full secondary or higher level of education. By 1990 this figure had risen to 69%. For women these figures were 28% and 73% respectively (CBS/Labour Force Survey, 1991). It is therefore not surprising that the average Dutch employee says that the content of his job no longer corresponds with his education. Forecasts made by the Central Planning Office suggest that the level of education of the working population will continue to increase to the year 2000, although less sharply than in the 1975-1985 period (Op de Beke & Arts, 1987). 6.6

Norms and values about work

Around the time of the Enlightenment (18th century) and the Industrial Revolution (beginning of the 19th century) norms and values about work changed drastically. Work rather than religion comes to occupy a central position in life. Apart from the the negative meaning of an imposed duty, work acquired a more positive meaning (possibility of personal development, a right). These attitudes towards work are also called the traditional work ethic. Although there have been radical changes related to work (through advances in technology and the rise in unemployment), the evidence suggests that the traditional woric ethic remains firmly entrenched in the Netherlands. In 1986 work was one of the most important things in life for 68% of the Dutch population aged 18-70 years. Only 11% found work of little importance. Work therefore still takes a central place in the life of many (Zanders et al., 1988). In comparison with other countries, such as Japan, the USA, Israel and Belgium, the central position of work in the Netherlands is relatively low. Only in West Germany and Great Britain is work given an even less central position (Meaning of Work-team, 1987). In the Netherlands the intrinsic value of work, e.g. autonomy, personal development, interesting work and personal contacts, is stressed. Obtaining social status is less important for Dutch people (Zanders et al., 1988; Meaning of Work-team, 1987).

77

Although these opinions are valid for the average Dutch person, there are groups whose value patterns differ. Older people appear to accord work a more central place than younger people and also have a stronger feeling of duty. The right to work is a concept more supported by younger people. Differences between men and women are not very marked. Men tend to place work slightly more centrally than do women, and are more likely to see as a duty. Slightly more women see work as a right (Zanders et al., 1988; Meaning of Work-team, 1987). 6.7

Summary and conclusions

On the basis of the developments in age, education and value pattems, trends in the past two decades with respect to work capacity can be summed up as foUows: the physical work capacity has diminished somewhat as a result of the fact that there are more women in the labour force and that the average age has risen slightly. There are more employees who have completed higher education, and these may may have increased the 'average coping ability' of the labour force. This makes it difficult to come to a final conclusion about the developments in the physical and mental work capacity in the past two decades.

78

THE HEALTH OF THE WORKING POPULATION

7.1

Introduction

Performing work can have consequences for the health of a worker. In this chapter six aspects of the health of the work force wiU be discussed in turn: (1) opinions about one's own health, (2) medical consumption, (3) sickness absence, (4) employment disability, (5) occupational diseases, (6) accidents at work. The groups at risk (by age, sex and industry and the developments over time will be dealt with in turn. Because no record is made of occupation or business in death certificates in the Netherlands, we can only speculate on this relationship. For this reason this topic will unfortunately have to be left out of this chapter. 7.2

Opinions of working people about their own health

In 1977, according to the Life Situation Survey of the CBS, 16% of the working population in the Netherlands described their health as 'could be better', 'not so good', or 'bad'. This percentage dropped to 12% by 1986 (see Table 7.1). There is little difference between men and women. Young people, not surprisingly, report a better state of health than older people. The differences between the various industries are small, with a maximum spread of 6% between services (12%) and agriculture (18%). Apart from asking for a general assessment of personal health, the Life Situation Survey of the CBS also asked questions about backache, headaches and fatigue. The percentage of working people who say that they sometimes suffer from backache has remained much the same: 24% in 1977 and 26% in 1986 (see Table 7.1). Backache occurs most frequently in agriculture and in the construction industry, and is more often reported by women than by men (see Figure 7.2). The percentage of working people who often report a feeling of fatigue has also remained more or less the same: 24% in 1977 and 23% in 1986 79

(see Table 7.1). Women and older persons suffer more from fatigue than men and younger people. Of the five industries, fatigue is most often mentioned in the service sector (see Figure 7.3). Complaints of headaches fell in the period 1977-1986 (see Table 7.1). Women and young people suffer more headaches than men and older people (see Figure 7.4), and those working in agriculture are more susceptible to headaches than those working in other branches. The conclusion to be drawn is that women and older people report the most health complaints. They therefore appear to be the people who are suffering from the largest workload. Generally speaking, backache and fatigue are complaints of older people, while headaches are a complaint of the young. Table 7.1

Assessment of own health by working people in the period 1977 . 1986. Source: CBS/LSS 1977

1980

1983

1986

own health 'could be better'. 'not so good', 'bad'

16

14

14

12

sometimes having backache

24

27

23

26

often feeling tired

24

23

23

23

sometimes having a headache

28

25

23

23

contact with G.P. in the last three months

41

38

34

39

used medicines in the last two weeks

33

32

27

28

80

Figure 7.1

Negative assessment of own health: differences between branches of industry, men and women and age categories (n=5708). Source: CBS/LSS, 1977, 1983 and 1986 combined

agriculture manufacturing construction transport services

men women

18-34 years 18-34 years

men

3 5 - 5 4 years

women

3 5 - 5 4 years

men

>• 55 years

women

>• 55 years

total working population 0 10 20 30 40 50 60 70 80 percentage 'could be betterVnot so goodV'bad'

Figure 7.2

Sometimes having a sore back: differences between branches of industry, men and women and age categories (n= 5752). Source: CBS/LSS, 1977, 1983 and 1986 combined

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-54 >- 55 >• 55

years years years years years years

total working population 10 20 30 40 50 60 70 percentage of affirmative answers

81

Figure 7.3

Often having a feeling of fatigue: differences between branches of industry, men and women and age categories (n=5758). Source: CBS/LSS, 1977, 1983 and 1986 combined aoriculture

manufacturing construction transport servicea

men women men women men women

18-34 18-34 35-54 35-64 >• 55 >• 56

years years years years years years

totai woricing popuiation 10 20 30 40 50 60 70 percentage of affirmative answers

Figure 7.4

Sometimes having a headache: differences between branches of industry, men and women and age categories (n= 5760). Source: CBS/LSS, 1977, 1983 and 1986 combined

agricuiture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-64 >• 66 >• 56

years years years years years years

total worthing population 10 20 30 40 50 60 70 percentage of affirmative answers

82

80

7.3

Visits to GPs and the use of medicines by working people

According to the data from die Life Situation Survey of die CBS, die number of visits to a GP made by the working population scarcely changed in die 1977 - 1986 period (Table 7.1). In addition, we see tiiat there were fewer contacts widi GPs in agriculture than in manufacturing and services (Figure 7.5). The figure also indicates that in general women make contact with a GP more often dian men, and that older people do so more often than younger people. The use of medicines by the working population appears to have been less in 1986 than in 1977 (see Table 7.1). It is also evident that fewer medicines were used by diose working in the construction industry and agriculture than elsewhere (see Figure 7.6). Figure 7.6 also shows that older people consume more medicines than younger ones and that women consume more than men, except in die older age group (55 and over). This last observation is also true of contacts widi the GP: female employees of 55 or over appear to be a relatively healthy group, widi fewer medical problems than their male colleagues. Figure 7.5 Contact with the GP in the last three months: differences between branches of industry, men and women and age categories (n= 5755). Source: CBS/LSS, 1977, 1983 and 1986 combined agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-54 >" 55 >• 55

years years years years years years

totai worthing population 10 20 30 40 50 60 70 percentage of affirmative answers

83

Figure 7,6

Medication in the last two weeks: differences between branches of industry, men and women and age categories (n= 5768). Source: CBS/LSS, 1977, 1983 and 1986 combined

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 35-64 >• 66 >• 66

years years years years years years

total wori(ing population 10 20 30 40 50 60 70 percentage of affirmative answers

7.4

Sickness absence

As noted in Chapter 1, there are two reporting systems in the Netherlands for sickness absence, in which fimis participate on a voluntary basis (NIPG and NIA). There is also a reporting system in which firms participate on a compulsory basis because of the sickness benefits to be paid (namely the data of the SVr). As is shown in Figure 7.7 below, the rate of sickness absence in manufacturing increased from 3.9% to 6.4% in the period 1952 - 1991. In 1978/1979 it reached a peak of 10%. The state of the economy has been a definite factor in this trend. One explanation for the increase is the changed composition of the labour force. Since the early 1960s more married, slightly older, women with children have been joining the labour force. Other possible explanations are that people report sick sooner than they used to (as a result of better health and changing norms and values regarding work and leisure) and

84

that there has been an increase in the total workload, which has not been accompanied by a sufficient increase in the time for recuperation (see previous chapter). Figure 7.7 Rate of sickness absence in the Netherlands 1952 - 1991 (for the most part in manufacturing). Source: NIPG/TNO, 1991 percentage 10 H

Among other things the recession and high rate of unemployment have been advanced as explanations for the fall in sickness absence after 1977/1978. Employees with a high rate of sickness absence are weeded out of the labour force on health grounds, via unemployment and employment disability rulings, and replaced with new employees with a low rate of absence (Kruidenier & Bakker, 1985). Another explanation for the fall may be the willingness to work extra hard, for fear of being made redundant. There are clear differences in sickness absence among men and women. The rate (see Figure 7.8) and frequency of absence in the Netherlands is higher for women than for men; the average duration of absence, however, is longer for men than for women. 85

The rate of sickness absence increases with age. Older people are on average sick for longer periods than younger people, but take sick leave less often (see Figure 7.8). Symptoms of 'wear and tear', both as a result of the ageing process and of many years spent in the labour force, are a factor. It appears from many statistical sources that manual laborers report sick more often and for longer periods than civil servants and that they therefore have a higher rate of absence. This difference is, of course, linked to differences in the quality of working life. Figure 7.8

Rate of sickness absence of men and women in the five age groups (averaged over 1988-1989). Source: calculations based on data from NIA (Klein Hesselink & Reuling, 1990)

I men

m women

Figure 7.9 provides an overview of the rate of sickness absence per industry (i.e. industrial insurance boards), averaged over two years (19881989). Branches of industry with a high rate of absence are 'government' (i.e. social work provision paid out of government funds), the textiles, stone, construction, metal, and clothing industries (11-14%). A low rate of absence is to be found in the following industrial associations: banks, agriculture, health care, shipping trade and bakers (5-6%). 86

Figure 7.9

Rate of sickness absence in the 25 branches of industry; average of the period 1972-1985. Source: SVr

work by handicapped-j construction industry butchers stone industry 4 textiles industry-f timber industry-{ health care 4 chemical Industry-{ metal industry-r graphic industry-{ metallurgy industry-{ food processing 4 hotels/restaurants -{ -others' dairy -i retail trade-{ tobacco industry transport -t harbours merchant navy agriculture-] bakers H banking -| national average

percentage

7.5

Prolonged employment disability

The Disability Insurance Act (known as WAO in the Netherlands; see Chapter 1 for more details) regulates the financial consequences of prolonged employment disability for people working for private companies, while the Public Sector Employees Pension Act (ABP) regulates these for civil servants and the General Disability Benefit Act (AAW) for the selfemployed and those who have been handicapped early in life. According to recent data the number of disablement benefit claimants stood at 882,000 at the end of 1990. Expressed in percentage terms, we have the following breakdown: 72% from private companies, 10% civil servants, 7% self-employed, 10% early-handicapped and 1% 'others'. For a proper interpretation of these data and these statistics it is important to distinguish between these categories. The early-handicapped category is best left out of consideration as work was not a factor in their becoming disabled.

87

In Figure 7.10 trends in the number of disabled persons (AAW/AOW) is given for the period 1968 - 1990 (exclusive of early-handicapped). It may be seen that the number of disabled persons increased from 163,000 in 1968 to 749,000 in 1990. But the total number in any year is of course determined by the inflow and outflow of disabled people. It appears that the increase in the inflow had almost stopped at the beginning of the 1980s. In 1986 the difference between the inflow and outflow was still only 15,000 people. But in 1989 - 1990 the inflow increased again while the outflow lagged behind: as a result, the total was increased by 34,000 people in 1990.

Figure 7.10 Total number of people disabled for work in the Netherlands 1968-1990 (WAO/AAW; exclusive of early-handicapped and 'others')- Source: AAf/Aof number of people disabled for work x 1000 785

800 H

727

626

662

690

582

600 H

514 402

400 H 313 261 215

200 H 1 6 3

y..wfi,,,^ I irn....,,.irn...., mn M|I i i m ,,,. tm,,.^,,,tm,,,^,,inrh,.^,,it-n,,

.,.jrri,,,M,

.irri....

1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990

The increase in the number of people newly disabled for work in the period 1968-1978 can be attributed in part to the economic developments in that period. Reorganizations, redundancies and high unemployment caused an increase in the inflow of disabled (Bijlsma & Koopmans, 1984; Van 't HuUenaar & Van Koningsveld, 1986). After 1978 fewer people were declared disabled in all age categories. This may be due to a changing age distribution in the working population, such

88

as a fall in the number of working people aged 60 - 65 years. This group has the highest probability of being declared disabled for work. It should be borne in mind that these numbers are absolute figures and that the total working population has increased by more than a million in the period 1968 - 1989. Taking the number of newly disabled persons per 1,000 insured persons in paid employment in Figure 7.11, we see that the rate increased between 1969 and 1978. It then fell sharply in the period 1980 - 1984, subsequently increasing again to 17 newly disabled persons per 1,000 insured persons per year in 1990. The sharp fall in the rate of new disablement between 1981 (23 per 1,000) and 1984 (13 per 1,000) has not been sufficiently explained and researched. This fall may be worth a separate study.

Figure 7.11 Number of people newly disabled for work, per year and per 1,000 persons insured. Source: GMD, 1970-1991 30-1

24 !2G Lea

25-J IS

20-J

17'17

15H 114 ^

ft

115

2S 2 3 ^ [23 LC7 1 1 F 7

\

'n

1( LEH7

14

|i2 /S7

M4^ 12 Ls7

ie

1

n

10-j

^1

M^M-Lpl MM MMM"MM

MU-MM

LpU' Ljl 11 uI t 1 Lpi 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1969

0-J

We shall now look at the sex and age aspects of being declared disabled for work.

89

Women nowadays have the same chance as men of being declared disabled. For both sexes the inflow in 1990 was 17 out of 1,000 insured. Women, however, after a long period of being ill, more frequently retire altogether from work than men and thus disappear from 'the books'. In these comparisons between men and women, the kind of work that people do should also be taken into account. It is therefore surprising that women and men have the same chance of being declared disabled: one would expect a lower chance for women. The risk of being declared disabled increases with age. Statistics show that about 29 disabled employees per 1,000 insured are aged between 45 and 55 and about 35 disabled per 1,000 insured are aged between 55 and 65. In other words, at least 3% of people over 45 years of age are declared disabled. Figure 7.12 shows the total number of disabled people per 100 people insured and receiving benefits, men and women by age category. We see that less than 1% of young people between the age of 15 to 24 is disabled, but that in the oldest age category 50% are disabled. Figure 7,12 Total number of people disabled for work (per 100 insured and receiving benefits), per age category and sex; average of five years (1986 - 1990). Source: GMD, 1991

16-64 years

men

90

Finally we may look at the relationship between industrial branch and employment disability. From a study by Schellart (1989) it appears that work-related factors were the cause of disability for 37% of the people disabled for work. In 49% of cases the cause lay outside of work and in 14% the cause was not directly attributable to either one or the other. Occupations with physical or mental stress factors or with a high level of unskilled work have a high risk of employment disability (Van 't HuUenaar & Koningsveld, 1986; Aarts & De Jong, 1990). The number of people disabled for work varies widely from industry to industry (see Figure 7.13). The average percentage of people disabled in all branches of industry is 14% of all insured persons. Industries associated with a high number of disabled are: mines, clothing, textiles, construction, stone and leather (24 - 41%). A low percentage of disabled people is to be found in banking, health care, retail trade and agriculture (8 - 10%) (Source: SVr, unpublished data 1984 - 1986). Figure 7.13 Total number of people disabled for work (per 100 people insured and receiving benefits) in the 25 branches of industry; averaged over three years (1984-1986). Source: SVr; unpublished data work by handicapped mining clothing industry textiles Industry construction Industry stone industry leather Industry ~| timber Industry A dairy -| harbours metal industry merchant navy tobacco industry food processing -l chemical industry-f metallurgy industry-{ hotels/restaurants • transport graphic industry < bakers butchers agriculture retail trade health care banking national average

91

1.6

Occupational diseases and disorders related to work

Occupational diseases Until the 1.1.1988 occupational diseases were defined in the Dutch Sickness Benefit Act as acute or chronic disorders which affect the insured (and for which the insured receive benefits) and which are the consequences of paid employment. From 1.1.1988 Section 9 of the Safety and Health at Work Act came into force. The definition of occupational disease has been broadened in such a way that disorders resulting from physical demands (such as musculoskeletal disorders) and mental demands (such as stress) can be now regarded as occupational diseases. It is impossible to estimate the true occurrence of occupational diseases in the Netherlands on the basis of the official figures. Willems (1987) estimates from international statistics that there may be an underestimate of 20%. This would mean in reality an additional 10,000 cases per year in the Netherlands. Occupational skin diseases caused by chemical and physical agents are the most common (98%) of reported occupational diseases, for both men and women (CBS, 1972-1991). A large number of the cases reported are linked to accidents or accidental events, such as bums, acid or alkaline bums of the skin and mucous membranes and the inhalation of chemicals causing lung oedema. On the basis of intemational literature Willems (1987) names the following industries as being responsible for important risk factors: metal, constmction, health care, timber and fumiture, catering, transport and food-processing. Because occupational diseases are underrepresented in the official Dutch statistics, it is impossible to present trends in occupational diseases on the basis of these data. Disorders related to work The World Health Organization (1985) names the following important work-related disorders: musculoskeletal disorders, mental disorders. Chronic Non-Specific Lung Disease (CNSLD), diseases of the circulatory system and certain forms of cancer. These disorders are common in the Netherlands as well, as can be seen from the statistics on sickness absence

92

and employment disability. In 1990 two stood out above the others: musculoskeletal and mental disorders (see Figure 7.14). The fact that these two disorders are predominant has led us to give them special attention in the rest of this study (see Chapter 8 and others).

Figure 7.14 Percentage distribution of people disabled for work, by diagnosis (1990). Source: based on GMD, 1991 (total= 100%; n=821,051) musculoskeletal dls. mental disorders vague complaints circulatory dis. neurological dis. injuries respiratory dis. neoplasms digestive dis. congenital anomalies endocr./metabolic infectious diseases diseases of the si
^^^^^^^^^^^^^^^^ ^^^^^^^^^^^^^^^^^^

28.9 27.7

10.2 8.9

10

16 20 percentage

25

30

36

Figure 7.15 shows trends in the three most important diagnostic categories per 1,000 insured persons in the period 1978 - 1990. Musculoskeletal and mental disorders reached a peak in 1980 - 1981, decreased in the mid1980s and then began to increase again until 1990. Diseases of the circulatory system decreased over the whole period. The developments in the two most important disorders is more or less identical to the developments in the total number of people newly disabled for work in the period 1978- 1990 (see Figure 7.11).

93

Figure 7.15 Number of people newly disabled for work per 1,000 insured (1978 - 1990), in the three most important diagnostic categories. Source: GMD 8-

6-

4-

0-^

1

1978 1979 1 9 8 0 1981 1 9 8 2 1 9 8 3 1 9 8 4 1 9 8 5 1 9 8 6 1 9 8 7 1 9 8 8 1 9 8 9 H i circulatory system

^ ^ mental disorders

^ ^ musculosiceletai sys.

Figure 7.16 Number of people newly disabled for work in 1990 per 1,000 insured, split up into age categories and three diagnostic groups. Source: based on GMD, 1991

16-64 years

circulatory system musculoskeletal sys.

94

mental disorders

In Figure 7.16 this is looked at in greater depth. We know that there were 15 people newly declared disabled for work out of every 1,000 employees in 1990. In Figure 7.16 we see that five out of 15 suffered from mental disorders, six from musculoskeletal disorders and one from circulatory diseases. Looking at the age distribution, we can see a strong relationship between age and the incidence of circulatory diseases and musculoskeletal disorders. The relationship between age and mental disorders is less strong. The figures are three out of every 1,000 in the 25-34 age group and eight out of every 1,000 in the 55-64 age group. Musculoskeletal disorders constitute the most important diagnostic category for both employment disability and sickness absence. 25-50% of the working population regularly have back complaints. Besides factors at work, factors related to the individual, such as age, muscle power, general condition and earlier back disorders, play a role (Hildebrandt, 1987). Women above the age of 40 are more often than men declared disabled for work as a result of musculoskeletal disorders (Van der Putten, 1985), but this is not the case with sickness absence. Industries in which musculoskeletal disorders are responsible for the employment disability of many people are dairying, construction, timber, textiles, stone, metals, chemicals, food-processing and transport. Mental disorders constitute the second most important diagnostic category for sickness absence and employment disability. The WHO (1985) estimates that 5% of the working population have serious mental disorders caused by work. Women are more often than men declared unfit for work because of mental disorders (Van der Putten, 1985). This diagnosis is also more common among women than men for sickness absence (SVr, 1972-1990). The graphic industry, government service and banks have a large number of people declared disabled on the grounds of mental health problems. The third important diagnostic category for employment disability is diseases of the circulatory system. This category scarcely plays a role in sickness absence. Men more often than women are declared disabled because of diseases of the circulatory system (Van der Putten, 1985). The stone and metal industries have a large number of people in this category. 95

A fourth important diagnostic category is Chronic Non-Specific Lung Disease. Approximately 5-10% of the Dutch population suffer from a form of CNSLD. Not enough is known of the percentage occurrence of chronic non-specific lung diseases and other diseases of the lungs in relation to occupation. Estimates vary from 2% in the US to 15% in Japan for bronchial asthma. Heederik (1990) concluded from his study that 10-30% of CNSLD is determined by work and occupational aspects. Other factors besides profession are relevant: sex, age, race, height and weight, socioeconomic status, place of domicile, smoking habits and prior medical history (Sorgdrager et al., 1988). Respiratory disorders form an important diagnostic category with regard to sickness absence (24% of the known causes). With regard to employment disability it is relatively unimportant. Men more often than women are declared disabled because of these disorders, the most important of which is CNSLD. Older people more often than younger people are declared disabled on those grounds (Van der Putten, 1985). Finally some information on work and cancer. The percentage of cancers due to work is put at around 2-8% (Doll & Peto, 1981). If one were only to look at that element of the working population where occupational cancers primarily occur (i.e. manual workers above the age of 20 in agriculture and fisheries, mining and manufacturing industries), then one out of every five cancers would be attributable to work (Saracci, 1985). Saracci (1985) gives an overview of occupations where (a) the causal relation between work and cancer has been established and (b) where a heightened cancer risk has been established but not a causal relation. As said earlier, the greatest risks are in agriculture and fisheries and in the mining and manufacturing industries. Since it is mainly men that work in those branches, occupational cancers will most often be found in men. Some people expect the incidence of occupafional cancers to fall gradually as a result of improved working conditions, cleaner production methods and a decrease in the number of jobs in the industries with the greatest risks (STG, 1988). Others, however, expect an increase in occupational cancers, for example in the chemical industry (Lahayle & Heulens, 1988).

96

7.7

Occupational accidents

In 1967 the Accident Act of 1901 was integrated into the Sickness Benefit Act. Since then the registration of accidents in the Netherlands has been far less complete. On the basis of comparative material from West Germany, Prins (1984) concludes that the rate of accidents there is approximately three times as high as in the Netherlands. This difference does not reflect reality, but better reporting in West Germany. As Figure 7.17 shows, the number of accidents per 1,000 male employees has faUen from 60 per 1,000 in 1968 to around 28 per 1,000 in 1988. With women the rate per 1,000 fell from 9 to 5. Figure 7.17 Number of occupational accidents per 1,000 employees 19681988. Source: Statistics of industrial accidents, CBS, 1972-1991 per 1000 employees

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1968

As men and women grow older the likelihood of occupational accidents lessens. The percentage of victims younger than 25 is much greater than would be expected from the age distribution of the working population. As to the consequences of occupational accidents, people aged over 30 run a greater risk of being admitted to hospital or dying as a result of an accident. 97

Finally there are marked differences in the number of occupational accidents in the various industries. Besides differences in the nature of working conditions, differences in age and sex distribution also play a role. The risks of accidents are greatest in the construction industry (52 per 1,000 employees), followed by agriculture and fisheries and the manufacturing industry (34 and 28 respectively per 1,000 employees). The risks are lowest in 'other services', excluding banks and insurance companies, (three accidents per 1,000 employees) (Source: CBS, 1991). 7.8

Summary and conclusions

In this chapter we have attempted to describe the health status of the working population in the Netherlands. It is worth mentioning that those in work appear to constitute the healthiest section of the population. Unemployed people and housewives, as well as people disabled for work, report far more health problems than people in employment. The working population has undergone a 'health improvement process' in the 1980s, because those who were less healthy disappeared from the work scene, either on a voluntary basis or more or less involuntarily. What is the present state of the health of the working population? And who are the groups at risk in relation to the branch of industry, sex and age categories? The answers to these questions do not always point in the same direction, but depend to a large extent on the health indicator being used. Three main data sources have been used: the Life Situation Surveys of the CBS (1977 - 1986), rates of sickness absence and diagnoses and rates of employment disability and diagnoses. From 1977 till 1986 there was a slight decrease (from 16% to 12%) in the number of working people who assessed their own health negatively. Strangely there was no decrease in complaints of backache and fatigue. The percentage of people reporting that they sometimes have a backache stayed much the same in the period 1977 - 1986 (24-26%), as did the percentage of people reporting that they are often tired (24-23%). The percentage of people who reported that they sometimes have a headache fell between 1977 - 1986 from 28% to 23%. Visits to the GP stayed much the same (41% and 39%), and the use of medicines fell (from 33% to 27%). 98

All things considered, the health of the working population, according to people's own subjective assessment, seems to have improved in 19771986. This may be due to selection and out-stream mechanisms, or to an improved quality of working life (see Chapter 5). Data on sickness absence and employment disability are available for extended periods. If we limit ourselves to the 1977 - 1986 period, we find that the rates of sickness absence and employment disability fell. Sickness absence in manufacturing fell from 9% to 7%; the rate at which people became disabled (per year, per 1(X) people insured) fell from 2.3% to 1.5%. The number of occupational accidents fell, although we do not know how many accidents went unreported. The available data seem to indicate that - in the period 1977 - 1986 - the health of the Dutch working population improved. Now to the groups at risk in the Dutch working population. Here it needs to be borne in mind that there health selection mechanisms are also acting on the working population in the Netherlands. It appears that the construction industry, consciously or unconsciously, discriminates against less healthy people, who disappear more quickly from that branch of industry than elsewhere. Summarising the branches of industry - without correction for age and sex distribution - the following picture appears (see Table 7.2).

Table 7.2

Summary of health by industrial branch

agriculture manufacturing construction transport services

assessment of own health

sickness absence and employment disability

-

+

0 +

0 +

'-' : below average '0' : average '+' : above average

99

In manufacturing, construction, the service industries and transport sector the two types of health indicator (assessment of own health and outflow from the labour force) do not contradict each other. But in agriculture they do: people's assessment of their own health is generally negative, yet sickness absence and employment disability are not above average. Possibly the fact that people in agriculture (who are mainly self-employed) cannot allow themselves to take days off for illness or to be declared disabled for work explains the contradiction. In the research literature this is referred to as 'the lack of opportunity'. Finally a few conclusions about sex differences and age differences related to health. The conclusions can be summarised in a few words. In the working population older workers and women are the most important groups at risk. These two groups score consistently the worst with regard to their own health, backache, fatigue, visits to the GP, use of medicines, sickness absence and the rate of entry into the pool of people declared disabled for work. There are two exceptions: men suffer more occupational accidents than women and young people are more prone to headaches and occupational accidents than are older people.

100

8

THE FUTURE OF WORK AND HEALTH: INTRODUCTION AND METHODOLOGY

8.1

The Delphi method in general

In Chapters 5 to 7 the actual work situation in the Netherlands and the health of the Dutch labour force were described. In this chapter we shall proceed to explore the future of work and health. This will be done by extrapolating trends form the past into the future and with the help of scenarios. The expectations of experts about possible future scenarios in the area of work and health were gathered by means of the Delphi method. This method entails experts giving their opinions, not through direct communication, but by completing two or three sequential questionnaires. The experts, who are unknown to each other, receive with each questionnaire a summary of the results of the previous round in the form of group answers. Having received this 'feedback' experts can adjust their opinions or stick to their original views. The Delphi method was originally used as a means of reaching a consensus of opinion among experts. In the last few years the ultimate aim has shifted from consensus to 'a certain degree of stability' in the answers over time. If, after a few rounds, the opinions of the experts show little further change, irrespective of whether there is consensus or not, the process of repetition can be halted. In practice three rounds appear to be sufficient to come to a stable group opinion. With more rounds there exists the possibility of the experts becoming tired of completing questionnaires. In a number of earlier scenario studies two written rounds were held, followed by a third, oral one or 'workshop' (STG, 1989, 1992). This third round was held in order to discuss the consistency and plausibility of the final scenarios. In our scenario study, two written rounds were held, in the period December 1989 - September 1990. Seven scenarios were presented: six explora101

tory ones and one goal-oriented one. A third oral round was not held because the extra results to be obtained from this round were not expected to justify the necessary investment of time. 8.2

The seven scenarios of the Delphi study Work and Health

In the first Delphi round questions about the future were asked in relation to five scenarios. These were composed of three scenarios determined by economic circumstances: a medium economic growth, high economic growth and low economic growth scenario, based on the long term explorations of the Netheriands' Central Planning Office (CPB, 1985). The other two scenarios in the first round were determined by new policies and the provision of care in the general field of work, health and well-being. The five scenarios may be described as follows: Scenario 1: Medium economic growth In this scenario the economic growth is similar to what it was in the last five years (1985-1990). National income grows by 2.7% per year on average and industrial investment by 3.5% per year till the year 2010. This scenario is considered the most probable development. Scenario 2: High economic growth A strong economic upturn, similar to the expansion period of 1951-1973, is assumed. Nafional income grows by 3.7% on average and industrial investment by 4.5% per year till the year 2010. Scenario 3: Low economic growth In this scenario the future developments can best be compared to the 1973-1985 period (from the first oil crisis). There is no question of a strong economic upturn. National income increases by only 1.7% per year and industrial investment by 2.5% till the year 2010. Scenario 4: Improvement in working conditions Since 1975 the Ministry of Social Affairs and Employment has operated a subsidy and incentive scheme for improving the quality of working life in Dutch industry. In this scenario it is assumed that the size of the scheme is extended to 200 million guilders (approximately $100 million) per year, to be spent on improving the quality of work and working life and on research and the provision of information. The Social Security Funds provide 145 million guilders of this total. 102

Scenario 5 : Extension of Occupational Health Care In the Netherlands there are around 200 occupational health care centres, providing care for 2 million employees. This means that 4 million employees (ca. 65% of all working people) do not receive occupational health care. In the Extension of Occupational Health Care scenario it is assumed that all employees and self-employed people in the Netherlands will receive occupational health care and that the number of occupational health care providers will triple. It is further assumed that the nature of the care does not change. The operating costs of occupational health care came to 330 million guilders (approximately $165 million) in 1989 (WVC, 1990). In this scenario the costs would triple. In the second round of the Delphi study the questions about work and health in the future were repeated, in the context of the five scenarios from the first round. Two other new scenarios were introduced. The 6th scenario is determined by both autonomous determinants and new policies: the internationalization scenario. The 7th scenario is a goal-oriented scenario, in which the question is posed of how a specific goal can be reached by means of concrete policy measures. The internationalization scenario was taken up on the basis of suggestions from the 120 panel experts consulted in the first round (see Table 8.3). These two scenarios were described as foUows: Scenario 6: Internationalization of economic life In the coming 20 years a further integration of Western Europe wiU take place. A large number of measures will be implemented in order to do away with barriers to free trade and the movement of people, hindrances arising from different rules and regulations, barriers to the transfer of capital and services, restrictions on government procurement and fiscal barriers. The consequences for companies in the Netherlands will be an increase in scale (through mergers and the closure of small firms), greater international cooperation, more competition, enlargement of the sales markets, and more high-technology firms (SER, 1989 and CPB, 1989). In the 1985-2010 period a common European policy will also come into being with respect to working conditions. A large number of directives will come into force with respect to the 'physical and mental protection of employees'.

103

Scenario 7: The goal-oriented scenario: reduction of sickness absence and employment disability The question raised is the following: What concrete measures can be taken to halve the number of people who annually become disabled for woric and to halve the rate of sickness absence? The measures may be concerned with the following areas: quality of working life, social insurance system, law, health care, financing, information, scientific research and company fitness programmes. 8.3

The selection of four industrial branches

Because the quality of working life and its developments are not the same in each industry, four industries have been selected that differ from one another in various ways: (1) 'agriculture', with around 280,000 employees; (2) 'manufacturing', with around 1.1 million employees; (3) 'the construction industry', with around 380,000 employees; (4) 'services', with around 4 million employees. These four industries vary greatly in size: agriculture and the construction industry are relatively small (5% and 7% respectively of the total working population), while manufacturing and the services are very large (19% and 69% respectively of the total working population). Agriculture and the construction industry are relatively homogeneous with respect to the composition of professions. Manufacturing and the services, however, are made up of very different professional and industrial groups. Account will have to be taken of this fact when results and conclusions are later discussed. 8.4

The experts consulted (members of the panel)

As the Delphi study focused on four industries, the experts in the Delphi study had to be recruited from these four areas. In choosing the experts the following criteria were used: - presumed knowledge of one of the four industries; - presumed knowledge in the area of work and health; - experts had to be involved in one of the following six categories of employment: government service, occupational health care, social insurance, employers' organizations, trade unions, academic institutions. 104

Finally 276 experts were chosen from the four industries and the six 'categories' of employment. These experts were asked to participate in the Delphi study and to complete the first round questionnaire. We assumed that the greater the number of experts, the more reliable the results would be. A minimum of 20 experts per industry was selected. Table 8.1 shows (1) the number of selected experts who were invited to participate in the Delphi study, (2) the number of experts who agreed to participate and to complete the first questionnaire and (3) the number of experts who completed the second questionnaire. The table lists the number of experts from each industrial branch and category of employment. Table 8.1

Experts in the first and second rounds of the Delphi study, total number, by industrial branch and category of employment (3)

(2)

(1) invited experts

participation first round

participation second round

n

n

in % of(l)

n

agriculture industry construction services

44 100 48 84

20 45 24 31

(45) (45) (50) (37)

16 28 20 24

(80) (62) (83) (77)

government service occupational health care social insurances employers' organizations trade unions academic institutions

43 68 15 38 29 83

13 36 9 8 9 45

(30) (53) (60) (21) (31) (54)

9 28 7 4 6 34

(69) (78) (78) (50) (67) (76)

Total

276

120

(43)

88

(73)

in % of (2)

105

120 experts completed the questionnaire in the first round and 88 experts in the second round. Participation in both rounds was highest among the experts from agriculture and the construction industry and among those from the occupational health care, social insurance and academic institutions. The lowest participation rates came from industry and services and from government service, employers' organizations and trade unions. 8.5

The questionnaires used

In § 2.6 a model was presented which served as a guide for the review of the actual work and health situation. This model also served as the basis for the questions asked in the Delphi study. Because the area of work and health is so broad, the model had to be reduced in a number of ways for the Delphi study. The most important reductions concern the area of health. In Chapter 7 we distinguished a number of health indicators which were considered most relevant to work situations. They were considered relevant because they often occur in the working population, are directly related to the quality of work and can be responsible for a lot of problems. The following four health indicators were chosen for the Delphi study: back complaints and stress reactions (two very common work disorders) and sickness absence and employment disability (two important indirect health indicators). 8.5.1 The questionnaire for the first Delphi round The questionnaire for the first round was made up of two parts, an explanatory note and a 20-page long questionnaire. The explanatory note was the same for all four industries, the questionnaire different for all four branches. The aim of the scenario study and the role of the Delphi study were explained in the explanatory note. Background information provided on the outline of the scenarios. The note also gave information on developments in the composition of the working population by age, sex and level of education in the 1975-2010 period: i.e. more women, more older people and higher education levels. The explanatory note also provided information about developments in the quality of working life and the four health indicators (back complaints. 106

stress, sickness absence and employment disability) in the 1974-1986 period. This information served by way of background to the questions about future developments in certain aspects of the quality of v^orking life and health. The most important part of the explanatory note was concerned with a description of the effects of the five scenarios on the quality of working life and on back complaints, stress, sickness absence and employment disability. A list of 23 aspects of the quality of working life and five aspects of health and well-being was presented (see Table 8.2). This list was made on the basis of items/questions which appear in the three most often used work-oriented surveys in the Netherlands (the Life Situation Survey, the NIPG Survey of Work and Health and the Periodic Occupational Health Survey (in Dutch PBGO), which is often used by occupational health care centres) and of the data on sickness absence and employment disability of the Social Security Council (SVr). Each aspect of working life included in the list had - as far as possible - to meet two criteria: (1) it must have a relation with the four health indicators and (2) there must be recent data available on its occurrence in the working population in the Netheriands. The four health indicators were translated into five aspects, namely 'sometimes having backache' (for back complaints), 'often tired' and 'sometimes having a headache', (for stress reactions), the rate of sickness absence and the risk of employment disability (number of new people disabled per 100 insured in one year.) In the questionnaire itself, the experts were asked to indicate for each of the 28 aspects in each scenario to what extent (expressed by an expected increase or decrease of more than 10% or no change) they thought the situation would change by the year 2010. The possibilities in the first round were therefore presented on a three-point scale. In order to give the experts a starting point for comparison, information was given about the present occurrence of those 23 aspects; where no data was available, the experts were asked to estimate the present situation themselves.

107

Table 8.2

The 23 aspects of working life and the Five aspects of health and well-being in the Delphi study; percentages of affirmative answers of employees in the four industries over the period 1983-1986

Percentage of affirmative answers of employees averaged over 1983-1986 Agriculture

Job content Having work that is not closely related to education or experience Carrying out monotonous work Working at a high pace Working regularly under time pressure Having work that is mentally demanding Working conditions Working in a noisy environment Carrying out heavy physical work Working under unsafe conditions Working in the same posture for long periods Being regularly exposed to vibrations and shocks during work Being regularly exposed to toxic materials during work

Industry Construe- Services tion

28 13 37 41 22

35 17 39 53 54

35 12 50 48 32

34 11 46 56 70

13 50 13 50*

40 20 20 32*

39 55 18 33*

17 19 17 25*

25*

15*

21*

10*

33*

28*

28*

20*

Labour relations Working with too little possibility for consultation Not being able to make decisions about own work situation

12

24

14

20

35*

48*

55*

47*

Job conditions Working for less than 35 hours per week Working with variable working hours Working in shifts Needing more than 30 minutes to get to work No favourable promotion possibilities at work Uncertainty about future of job Work where sickness absence is strictly controlled Work where first days of absence remain unpaid

17 60* 0 52 85 19 36* 28*

10 24* 13 53 69 39 37* 16*

6 12* 21 2 78 26 52* 8*

30 46* 2 23 72 45 30* 18*

108

Work where no active measures are taken to prevent employment disability Work without rehabilitation programmes for partly disabled employees

75*

66*

76*

68*

80*

68*

76*

65*

Back complaints Sometimes having backache

31

24

31

24

Stress reactions Often tired Sometimes having a headache

19 14

22 22

15 17

25 25

Sickness absence Number of days of sickness absence as a % of the total number of working days per year

5

7,5

11

7

Employment disability Number of new cases of employment disability per 100 people insured per year

1,1

1,6

3,2

1,5

*: percentages estimated by the panel experts during the first round

Finally the experts were asked to name important macro-determinants which, in their opinion, were not mentioned or not given enough weight in the first round. As a result a new, sixth scenario, was set up for the second round. Table 8.3 shows the themes most often mentioned. The 'internationalization of economic life' was most often cited by the experts. Because 'internationalization' affected all four industries, this subject was chosen for the sixth scenario.

109

Table 8.3

Possible themes which, according to the experts, were neglected in the first round and which could be used for the sixth scenario (n=68); more than one answer was possible

Themes Internationalization of economic life Environmental issues Organization of care for work and health (quality and organization of the occupational health care) More/different attention to health and illness Developments in education Organization of the social security system Changes in production methods Defending the interests of workers by trade-unions Research/education/information dissemination in the area of work and health Unhealthy life-styles Human Resource Management in firms Other themes (21 in total)

number of times mentioned 23 15 15 6 5 4 3 3 3 3 3 lof2

8.5.2 The questionnaire for the second Delphi round The questionnaire for the second round consisted of a short explanatory note on the questionnaire and the questionnaire itself (total 26 pages). The most important item was the presentation of the results of the first round. These concerned the estimated developments in the 28 aspects of work and health within the five scenarios. The experts were asked again to indicate whether they expected an increase, decrease or stabilization for all six scenarios and for all 28 aspects of work and health, with the knowledge of what the panel of experts had answered in the first round. Because the three-point scale appeared to have been too undifferentiated, the experts were able to chose from a five-point scale in this round. ++ : an increase by the year 2010 of 50% or more in comparison with the present situation. + : an increase by the year 2010 of 10-50% in comparison with the present situation.

110

0

: :

--

:

a decrease or increase by the year 2010 of 10% or less in comparison with the present situation. a decrease of 10-50% by the year 2010 in comparison with the present situation a decrease of 50% or more by the year 2010 in comparison with the present situation.

The last part of the questionnaire was concerned with the goal-oriented scenario. The experts were asked to indicate concrete policy measures which would lead to a halving of the people yearly declared disabled for work and to a halving of sickness absence in the Netherlands. Nine sets of measures in nine policy areas were given in the explanatory note as possible suggestions: in the area of work and health inside and outside the firm (i.e. at the industrial branch level); in the area of the social insurance system, in the legal system, in occupational health care, in the financial area, in the dissemination of information, in scientific research and in fitness programmes within firms. At the same time the panel was asked to estimate the costs of such measures. The results of this scenario are given in Chapter 10. 8.6

Method of analysis of the answers to the questionnaires

The results of the second round, though not those of the first, were analysed on the basis of the answers of the 88 members of the panel. These results are given in Chapters 9 and 10 of this book. For this analysis the following procedure was used. First, the answers of the panel on the five-point scale were translated into quantitative values of +60%, +30%, 0%, -30% and -60% respectively. Second, these values, indicating the percentage changes for the period 1983/1986-2010, were translated into the actual percentages for the year 2010. Third, these percentages for the year 2010 were weighted, taking into account the size of the four industries. In other words: the answers obtained for industry and service sector were more heavily weighted than those obtained for construction and agriculture. Through the use of this weighting, the percentages for the year 2010 give a representative picture of the future developments expected by the experts in the area of work and health for the whole working population of the

111

Netherlands. The results for services have a large influence on the results for the total working population of the Netherlands. 8.7

The quality of the results of the Delphi study

Before presenting the results of the Delphi study in Chapter 9 and 10, we shall first briefly discuss the quality of the results. The results of the Delphi study consist of predictions made by experts on the future developments of work and health. The results will be presented as averages of the answers provided. In calculating averages there exists the danger that opposite opinions can cancell each other out. To give an extreme example: if 50% of the experts answer '++' and the other 50% '- -', then the average result will be 'no change'. It is therefore important to examine the experts' answers. If there is a clearly bimodal distribution, as in the example above, the average will provide an incorrect impression of the true answers. This will be further discussed in section 8.7.1. The homogeneity or heterogeneity of the answers may be a result of such factors as the influence of the data of the first round on the second round, the influence of the professional category to which the expert belonged, the influence of the degree of expertise or the effect of the drop-out of 32 experts in the second round. The influence of this type of factor is discussed in § 8.7.2-8.7.5. 8.7.1 The homogeneity of the answers of the experts From the results it is evident that there a bi-modal distribution applies in only one variable in only one of the six scenarios: approximately the same number of experts there predict '++' or '+' as '- -' or '-' and only a small number say '0'. The average of this variable does not therefore properly reflect the opinions of the experts. The answers of the 88 experts are on average well distributed between the four categories of answers on both sides of the 'no change' point. If we examine the homogeneity of the answers in each scenario, it turns out that the experts give the most similar answers in the medium economic growth scenario (i.e. the reference scenario). The greatest 112

diversity of answers is to be found in the high economic growth scenario and in the international scenario. It was probably the most difficult for the experts to make predictions about the future in those two scenarios. All things considered, it may be concluded that there is no objection to using the average to represent the answers of the experts. HJ2 Impact of the feedback from the first round on the answers in the second round In a Delphi study the intention is to bring about a change of opinion by giving a feedback of the opinions in the first round. Did this happen in our case? The differences in the answers between the two rounds were tested for significance with a t-test. A significant difference in a number of variables was found between the scores of the first and second round. The opinions in the second round were more extreme (more 'increases' and 'decreases' than 'no changes') than in the first round. The experts who differed from the 'total-average' in the first round probably conformed more to that average in the second round. The spread of the answers in the second round was less than in the first. By carrying out the second round of this Delphi study, a greater consensus was reached in the answers. This tendency to homogeneity is known as the 'Delphi effect'. The purpose that was intended had been achieved. However, a considerable spread was still present at the end of the second round. The second round had a definite purpose. Many experts reviewed their opinion as a result of the feedback. The improved instructions for the completion of the second questionnaire probably also played a role. Given die limited time available, no third round was attempted. 8.7.3 Influence of experts' occupation on the responses As noted earlier, the experts belonged to six different categories of employment, namely government service, occupational health care, social insurance, employers' organizations, trade unions and the academic community. The spread of the 'total-average' of all 88 experts can be 113

partly attributed to differences in opinion due to the category of employment they belonged to. We examined how far the average scores of these six groups differed from one another. There proved to be no significant differences between these six categories of employment. In neariy all scenarios there was a definite difference between the six categories of experts on only one topic. This result may therefore have been due to chance. The question as to whether the experts from directly interested occupations answered differently in the two policy scenarios from the other experts was also examined. It seems, however, that in the scenario based on improving working conditions, and the scenario based on the extension of occupational health care the answers of those who might be said to have a vested interest (e.g. employers in the first scenario or health care providers in the second) did not differ significantly from the answers of those in other categories. It may be concluded that the spread of the 'overallaverage' is not greatly influenced by differences in the six categories of employment. When the results are discussed in Chapter 9, the six categories of employment will not be discussed any further. 8.7.4 Influence of self-selection of the experts and the degree of expertise on the answers As was shown in Table 8.1, 276 potential candidates were invited to participate in the study. Those who did not wish to participate simply did not complete the questionnaire. The selection was therefore determined by the potential candidates themselves. 34 people formally declined to participate. The two main reasons given were lack of rime and lack of expertise. This latter reason shows that some degree of self-selection took place with respect to the expertise required. A second form of self-selection took place after the first round. 32 of the original 120 experts chose not to participate in the second round. The next question is how far the results of the second round were influenced by the 'non-response' of 27% of original participants. We know to what extent those who participated only in the first round considered themselves 'expert' in the different areas. In Table 8.4 the self-reported degree of expertise of the 88 experts who participated in both rounds is shown next to that of the 32 experts of the first round. We see that for all topics the 114

experts in the second round give a higher estimate of their own expertise than those who participated only in the first. There was therefore a second form of self-selection: those who considered themselves less 'expert' decided to drop out after the first round.

Table 8.4

Self-reported degree of expertise of the experts in the area of work and health Only first round (n=32) % reasonably/ very expert

Both rounds (n=88) % reasonably/ very expert

Macro-determinants demography technology opinions about work and leisure policy on work and health

33 48 48 87

61 58 66 88

Quality of working life job content working conditions labour relations job conditions

81 87 68 52

86 94 76 52

Health back disorders stress reactions sickness absence employment disability

53 58 74 71

63 72 79 70

One last question is concerned with whether these two forms of selfselection on expertise could have had an influence on the results. In other words do the views of the less expert participants (those who describe themselves as 'little expert') differ from those of the more expert (reasonably/very expert), and if so should the views of the latter be given more weight?

115

The differences between the opinions of the two groups of experts on the 28 questions in the second round were tested with a t-test (see Table 8.4). In general there were no great differences to be found in the average scores of both groups. Significant differences were found only for a few questions. From this it may be concluded that the Delphi results are not greatly affected by differences in the expertise of the panel members. The same is true of other scenario studies: in the scenario study Accidents and Traumatology (STG, 1989), hardly any difference was found in the answers of the experts by degree of expertise. In Chapter 9 the results of the 'experts' who participated in both rounds will be presented. From now on, whenever experts are mentioned in this report, we shall be referring to these 88 experts. The experts who participated in both rounds and who provided the basis for the results did not represent a random sample, but a 'select company'. First of all, only people who were considered suitable for this study were selected. Then a form of self-selection on the grounds of expertise took place twice during the study. The self-reported degree of expertise should therefore be seen in that light. Those who stated that they had little expertise had a good deal more than the average Dutchman. It is not therefore surprising that there are scarcely any differences between the answers of the panel members who consider themselves 'reasonably/very' expert and 'little' expert. 8.8

Summary

In this chapter we have explained how the Delphi study was carried out. The seven scenarios have been described. It was noted that the experts were recruited from four sectors (industry, services, construction and agriculture) and from six categories of employment (government service, occupational health care, social insurance, employers' organizations, trade unions, and academic institutions). In the first Delphi round 120 experts participated; in the second 88 did so. A description of the contents of the questionnaires was then given. Finally the quality of the results was discussed. We established that there are no objections to using the average scores of all 88 panel members in the presentation of the results because the distribution of the answers obtained in the five quesfion categories allows this. We also concluded that the Delphi method worked as planned; by carrying 116

out a second round, there was a greater consensus between the members of the panel. The greatest consensus was found in the medium economic growth scenario. The least consensus and consequently the greatest uncertainty as to their value was found in the high economic growth scenario and the internationalization scenario. Of the two policy scenarios the scenario concerned with the improvement in working conditions shows the smallest spread of answers. The results of this scenario are therefore somewhat more reliable than those of the occupational health care scenario. We also found that belonging to a certain category of employment (employer, employee, care provider, etc.) had little or no influence on the opinions about work and health in the future. Furthermore we showed that selection on the grounds of expertise occurred twice in the course of the Delphi study: the people with less expertise either did not participate or dropped out after the first round. Finally we argued that the selection on the grounds of expertise had little influence on the results, as it could be shown that the opinions of the members of the panel with slightly more or less expertise differed little from one another about the future of work and health.

117

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RESULTS: THE SIX EXPLORATORY SCENARIOS

9.1

Introduction

In this chapter the results of the six exploratory scenarios will be presented. In § 9.2 each of these scenarios will be compared with the others. The relationship between them will then immediately become apparent, so that the consequences of the results can be seen in the correct perspective. The developments in the quality of working life in each of the six scenarios will be described in § 9.3, while future developments in the four health indicators will be outlined in § 9.4. § 9.5 describes the most striking differences in the quality of working life and the four health indicators between the four sectors. 9.2

The six exploratory scenarios compared

In defining the scenarios, an attempt was made to select a number of 'extreme' future situations that were nevertheless realistic and imaginable. A medium economic growth or reference scenario in which things remain much the same in the area of work and health was chosen first of all. Two 'extreme' contrasting growth scenarios were defined around it, namely the high and the low economic growth scenarios. Two 'extreme' policy scenarios were then chosen, namely the medium economic growth scenario with extensive improvements in working conditions, and the same scenario with occupational health care available to all employees. Finally, the internationalization scenario was chosen by the experts, in which both economic developments and policy are determined by the internationalization of economic life. The question now is to determine whether the effects of these six scenarios, as predicted by the experts, do in fact differ from one another.

119

In order to gain an insight into this question, we correlated the averages of all 28 variables between the six scenarios (see Table 9.1). All correlations, as shown in Table 9.1, are positive. This means that there is no question of scenarios contradicting one another in a fundamental way. All scenarios point in the same direction. It also turns out that two pairs of scenarios are very strongly related (with a correlation coefficient of 0.71) and that they are therefore very similar in their predictions about the future. The two pairs of scenarios are the reference scenario (with medium economic growth) and the high economic growth scenario, and the two policy scenarios, the Improvement of working conditions scenario and the Extension of occupational health care scenario. This relationship can also be seen in Table 9.2 and will be further discussed in the following sections. If we look, for example, at the aspect 'carrying out heavy physical work', then this will decrease according to the experts from 23% in 1983/1986 to around 18% in 2010. In the two policy scenarios, however, the experts expect this to drop even further. In Table 9.1 we can also see the relatively weak relationship between the low economic growth scenario and the other scenarios. The two scenarios that show the least similarity are the low and high economic growth scenarios. As can be seen in Table 9.2, the predictions for these two scenarios are completely different with respect to a number of aspects of work and health. Examples of this are 'not being able to make decisions about own woiic situation' and 'no favourable promotion possibilities at work', where the positive developments in the high economic growth scenario contrast with the negative developments in the low economic growth scenario. Table 9.1 shows that the internationalization scenario bears no clear relationship to the other scenarios. The results of Table 9.2 show that this scenario scores somewhere in the middle in comparison with the other scenarios.

120

Table 9.1

Correlations between the six scenarios (based on the average of all 28 variables in the second Delphi round) medium economic growth

medium economic growth high economic growth low economic growth improvmg working conditions extension of occupational health care

high economic growth

low economic growth

improving working conds

extension occup. health care

intern, economic life

0.71

0.46

0.58

0.52

0.53

0.25

0.50

0.43

0.50

0.33

0.30

0.35

0.71

0.55

0.48

internationalization of economic life

9.3

Favourable and unfavourable developments in the quality of working life 1983/1986 - 2010

The 88 experts who took part in the second Delphi round were asked how the quality of working life would change in the period 1983/1986 - 2010. In Table 9.2 the differences between 1983/1986 and 2010 are shown for all six scenarios. The percentages for 1983/1986 are also shown in the table. The increases and decreases expected by the experts have been indicated by an absolute percentage. Working in a noisy environment will,

121

for instance, fall from 23% in 1983/1986 to 18% in 2010. These are estimates which have been weighted for industry size and which are more or less representative for the whole working population in 2010.

Table 9.2

DifTerences in the quality of working life between 1983/1986 and 2010 in six scenarios according to 88 experts in the second round of the Delphi study Absolute change in

Percentage 1983-1986 medium high econ. econ. growth growth

low econ. growth

improv. working conditions

ext. occup. health care

internationalisation

work not closely related to education/experience monotonous work high pace time pressure mentally demanding work

34 12 44 54 61

1 -0.5 6 11 7

0.5 -0.5 11 16 12

8 2 9 10 4

-2 -2 -1 2 4

0 -0.5 1 4 4

0 0 8 11 8

noise heavy physical work unsafe conditions same posture vibrations/shocks toxic materials

23 23 17 *28 *13 *23

-5 -5 -3 -2 -2 -3

-6 -5 -4 -3 -3 -3

-1 -1 0 -0.5 -0.5 -1

-7 -7 -5 -8 -4 -7

-6 -6 -4 -6 -3 -7

-4 -4 -2 -2 -2 -3

20

-2

-3

0.5

-3

-2

0

*48

-7

-11

4

-9

-4

-2

<35 hours per week 26 shift work 11 travel time > 30 mins 22 no promotion possibilities 69 no prospects in employment situation 41 variable working hours *40

6 1 1 -2

6 3 4 -14

5 1 2 11

2 -0.5 -0.5 -7

3 0 0 -1

2 1 3 -8

-0.5 9

-9 11

8 5

-3 5

-0.5 4

-3 8

*33 *18

3 0

1 -1

6 3

1 -0.5

4 0

3 2

*69

-14

-19

-1

-19

-21

-11

*67

-12

-19

1

-17

-21

-5

not enough consultation not being able to make decisions about own work

stringent control of sickness absence first days of absence unpaid no active prevention against employment disability no active reintegration into the labour force

*: percentages estimated by the experts of the Delphi study in the first round.

122

In this section the predictions of the experts have been subdivided into 'favourable' (where the quality of working life will improve) and 'unfavourable' developments. It is not clear whether some aspects should be described as favourable or unfavourable, as with variable working hours and stringent control over sickness absence. These aspects will be discussed separately. A number of striking results will be given as an illustration. Favourable developments in the quality of working life In all six scenarios the 88 experts expect the following eight favourable developments to take place (see Table 9.2): a reduction in working in a noisy environment (see Figure 9.1), less heavy physical work (see Figure 9.2), a reduction in work in the same posture, and less exposure to vibration/shocks and to toxic materials (see Figure 9.3). They also expect more part-time work (less than 35 hours per week) (see Figure 9.4) and less work where no active measures are taken to prevent employment disability.

Figure 9.1

Percentage of the working population working in a noisy environment: differences between 1983/1990 and 2010 in the six scenarios percentage

16 increase 10

23%

-10 decrease -16 high econ. growth

low econ. growth

med econ. improv.work. extens. growth condit. occ. health

international.

123

Figure 9.2

Percentage of the working population carrying out a lot of heavy physical work: difference between 1983/1986 and 2010 in the six scenarios percentage

23%

high econ. growth

Figure 9.3

low econ. growth

med. econ. improv.work ext.occ. growth cond. health care

internation.

Percentage of the working population regularly exposed to toxic materials: difference between 1983/1986 and 2010 in the six scenarios

percentage

23%

high econ. growth

124

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

Figure 9.4

Percentage of the working population working less than 35 hours per week: difference between 1983/1986 and 2010 in the six scenarios

percentage 16 increase 10

26%

-6|-

-10 decrease! •16 high econ. growth

Figure 9.5

low econ. med improv.work ext.occ. growth econ.growth condit. health care

internation.

Percentage of the working population carrying out monotonous work: difference between 1983/1986 and 2010 in the six scenarios

percentage increase 10

l

2

\

0 KaaassKssiaM

PJja88888i88&58a

-0.6

-0.6

^^^

^ -^2 1

12%

^Pg88a888^SS6^M

-0.6

-6

-10 decrease

1

J._. _

high econ. growth

low econ. growth

med econ. improv.woric ext.occ. growth condit. health care

internation.

125

Seven aspects of the quality of working life are expected to develop favourably in all scenarios except for the low economic growth scenario: in comparison with 1983/1986, there will be less monotonous work (see Figure 9.5), less work where there is not enough consultation, less work where one is not able make decisions about one's own work situation, less work where there are no favourable opportunities for promotion (see Figure 9.6), less work where there are unsafe working conditions and less work where people who are partly disabled are not actively reintegrated in the labour force.

Figure 9.6

Percentage of the working population without favourable promotion possibilities at work: difference between 1983/1986 and 2010 in the six scenarios

percentage

69%

high econ. growth

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

Unfavourable developments in the quality of working life In the period up until the year 2010 the experts predict an increase in 'regularly working under pressure' (see Figure 9.7) and 'having work that is mentally demanding' (see Figure 9.8) in all six scenarios. Four other aspects of the quality of working life are expected to develop unfavourably in the high, low and medium growth and internationalization scenarios: increase in 'working at a high pace' (see Figure 9.9), increase in 'work that is not closely related to education/experience' (see Figure 9.10),

126

more 'working in shifts' and increase in 'travel time of more than 30 minutes'. An increase is also expected in all scenarios in 'having variable work times' and 'stringent control of sickness absence'. 'Having work where first days of absence remain unpaid' will show little change, except in the low economic growth scenario and the internationalization scenario where this aspect is expected to increase. Figure 9,7

Percentage of the working population regularly working under time pressure: difTerence between 1983/1986 and 2010 in the six scenarios

percentage increase 16 10 6 54%

0 -6 -10 -16 decrease high econ. growth

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

127

Figure 9.8

Percentage of the working population carrying out work that is mentally very demanding: difference between 1983/1986 and 2010 in the six scenarios

percentage

61%

-16 high econ. growth

Figure 9.9

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

Percentage of the working population carrying out work at a high pace: difference between 1983/1986 and 2010 in the six scenarios percentage

16 increase

11

10

44%

-5

-10 decrease -16 high econ. growth

128

low econ. growth

med econ. improv.woric ext.occ. growth condit. health care

internation.

Figure 9.10 Percentage of the working population with work that is not closely related to education/experience: difference between 1983/1986 and 2010 in the six scenarios percentage

34%

-16 high econ. growth

9.4

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

Favourable and unfavourable developments in health 1983/1986 - 2010

The predictions of the experts with respect to the four health indicators can also be subdivided into 'favourable' and 'unfavourable'. The differences between 1983/1986 and 2010 are shown in Table 9.3 for all six scenarios, together with the confirmatory percentages of 1983/1986. Favourable developments in the four health aspects The 88 experts expect that in the period 1983/1986 - 2010 there will be predominantly positive developments with respect to sickness absence (except in the high growth scenario) and the risk of employment disability (except in the medium and low economic growth scenarios). The developments can be seen in Figures 9.11 and 9.12.

129

Unfavourable developments in the four health aspects Except in the Improvement in working conditions scenario and the Extension of occupational health care scenario, back complaints and stress reactions will slightly increase, see Figures 9.13 and 9.14.

Table 9.3

DifTerences in the health indicators between 1983/1986 and 2010 in the six scenarios according to 88 experts Percentage 1983-1986 medium high low econ. econ. econ. growth growth growth

backache stress reactions rate of sickness absence probability of employment disability

25 23 7.4 1.4

1 3 0.2 0

Absolute change in improv. working conditions

1 5 1.2

2 4 -1.6

5 1 -1.7

-0.1

0.1

-0.4

ext. occup. health care

4 2

internationalisation

-1.3

0 2 -0.9

-0.3

-0.2

Figure 9.11 Rate of sickness absence: difference between 1983/1986 and 2010 in six scenarios percentage increase

1.2 0.2 7.4

%

-1.6

-6 decrease high econ. growth

130

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

Internation.

Figure 9.12 Risk of employment disability: difference between 1983/1986 and 2010 in six scenarios increase 10

14 -3

-6

-2

-10 decrease high econ. growth

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

Figure 9.13 Percentage of the working population that sometimes has backache: differences between 1983 and 2010 in six scenarios percentage 15 increase 10

25%

-6 -6 '10 decrease -16 high econ. growth

low econ. growth

med econ. improv.work ext.occ. growth condit. health care

internation.

131

Figure 9.14 Percentage of the working population that sometimes has stress reactions: difference between 1983/1986 and 2010 in six scenarios percentage

increase

high econ. grovirth

9.5

low econ. growth

med econ. improv.work extocc. growth condit. health care

internation.

Differences in work and health between the four sectors 1983/1986 . 2010

The future developments in the quality of working life and the four health indicators, as estimated by the 88 experts, were described in § 9.3 and 9.4 for the working population as a whole. In this section the results of the four sectors will be compared with those of the whole working population. The future developments in the four sectors of industry agree on ten aspects of working life and on one of the health aspects with the picture that was sketched for the whole working population. With respect to 13 aspects of the quality of working life and three health aspects, there is a significant difference between the four sectors and the whole working population (see Table 9.4).

132

Table 9.4

Differences in the future developments of work and health between the whole working population and the four sectors (average of the six scenarios)

General future development

Exceptions in industrial sectors

* less close relation between education/experience and job content * less monotonous work

* expected particularly in manufacturing but not in the construction industry * expected particularly in manufacturing but not in the construction industry * expected particularly in the construction industry, but below average expectations in agriculture * expected particularly in manufacturing * expected particularly in the construction industry, but below average expectations in agriculture * expected particularly in manufacturing, but below average expectations in agriculture * not expected in agriculture

* more work under time pressure

* less noise at work * more safety at work

* more consultation at work

* more people working a shorter working week * more work in shifts * more travelling time required between home and work

* less exposure to toxic materials * more work with variable working hours

* more application of unpaid days during sickness absence * more prevention of employment disability

* fewer back complaints * decrease in rate of sickness absence * decrease in risk of being made disabled for work

* expected particularly in manufacturing but not in agriculture and the construction industry * expected particularly in the construction industry, but below average expectations in agriculture * expected particularly in agriculture * expected particularly in manufacturing and below average expectations in the construction industry * exp)ected particularly in the construction industry but not in the other three sectors * more than average expectations in the construction industry and the services and less than average in agriculture and manufacturing * expected particularly in the construction industry but not in the services * not expected in agriculture * not expected in agriculture

133

9.6

Summary

The future developments in the field of work and health as estimated by the 88 experts who took part in the second round of the Delphi study have been described in this chapter. The results have been adjusted in such a way as to make them applicable to the working population of the Netherlands as a whole. The 88 experts made the following predictions for the year 2010: favourable changes in all scenarios: - noise (less) - heavy physical work (less) - working for long periods in the same posture (less) - exposure to vibration/shocks (less) - exposure to toxic materials (less) - part-time work (more) - active prevention of employment disability (more) favourable changes in all scenariosy except for the low economic growth scenario: - monotonous work (less) - safety at work (more) - consultation about work situation (more) - joint consultation about own work situation (more) - good promotion opportunities at work (more) - good prospects in employment situation (more) - activities directed at the reintegration of people who are partly disabled for work into the labour force (more) favourable changes in all scenarios, except for the high and medium economic growth scenarios: - sickness absence (less) favourable changes in all scenarios, except for the low and medium economic growth scenarios: - the risk of employment disability (less) unfavourable changes in all scenarios: - working under time pressure (more) - work that is mentally very demanding (more)

134

unfavourable changes in all scenarios, except for the Improvement of working conditions scenario and the Extension of occupational health care scenario: - no close correspondence between work and education/experience (more) - working at a high pace (more) - shift work (more) - travelling time longer than 30 minutes (more) - back complaints (more) - stress reactions (more) Furthermore the experts predict an increase in variable working hours and in stringent control of sickness absence in all scenarios. The number of unpaid days of sickness absence will show little variation. Improvement in working conditions and extension of occupational health care to the total working population have, according to the experts, a strikingly favourable influence on most aspects of the quality of working life and on the four health indicators. This chapter also examined whether the future developments of work and health described for the whole working population were also valid for the four sectors of agriculture, manufacturing, construction and services. The results for the four sectors appeared to coincide with those of the whole working population in approximately half the aspects related to the quality of working life and half the health aspects. Significant differences were found in the other half.

135

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10

RESULTS: THE GOAL-ORIENTED SCENARIO

10.1 Introduction The seventh scenario in the Delphi study is a 'goal-oriented' scenario and therefore differs from the other six 'exploratory' scenarios. In a goaloriented scenario the goal is determined at the start and the question to be resolved is how this goal can best be reached. The goal of our scenario was to halve the number of people who are yearly declared disabled for work and to halve the rate of sickness absence in the Netherlands by the year 2010. The 88 experts in the second round were asked to indicate what concrete measures would be required in order to reach this goal. The measures could lie in several suggested areas or if necessary in other areas of the experts own choosing. The areas suggested were: the quality of working life, the social security system, legislation, the provision of care, financing, education on work and health, scientific research and company fitness programmes. In order to obtain an insight into possible priorities, the experts were asked to indicate which two measures they thought should have the highest priority in the attempt to reach the goal in question. They were also asked to estimate the yearly costs which these measures would entail and to indicate who should pay for them. The proposed measures in the nine suggested areas wiU be discussed in § 10.2 and 10.3. The relevant costs will be discussed in § 10.4. A summary of this chapter is to be found in § 10.5. 10.2 Setting priorities in the nine policy areas Before we go into greater detail about the measures proposed by the members of the panel, we shall provide an overview of the priorities in the nine broad policy areas. First the two measures given highest priority by individual experts were classified according to the area of policy to which 137

each measure belonged. A number of experts indicated only one priority or none. Table 10.1 shows that most experts thought measures in the area of social security deserved the highest priority, followed by measures in the area of the quality of working life inside the company and the provision of care. Policy measures related to company fitness programmes, scientific research and education on work and health were given priority by only a few experts. It was agreed, however, that the application of the results of scientific research would have an effect.

Table 10.1 Ranking of measures proposed in ten broad policy areas in order to halve the number of people annually declared disabled for work and to halve the rate of sickness absence (maximum of two priorities per person: n=max. 176)

Policy area by rank

1 2 3 4 5 6 7 8 9 10 Total

social security system quality of working life inside company provision of care financing legislation quality of working life inside industrial sectors other policy areas company fitness programmes scientific research education on work and health

Number of times mentioned as having highest priority

51 34 17 14 12 9 6 4 3 3 153

In the next section we will look at the concrete measures proposed in the first three of these policy areas.

138

10.3

Concrete measures in the three most important policy areas

The experts have proposed concrete measures in each of nine policy areas. The concrete measures proposed in the first three policy areas, namely 'social security system', 'quality of working life' and 'provision of (occupational) health care', will be discussed in this section. These measures are shown in Table 10.2. Concrete measures in the area of social security have been summarized under the heading 'financial punishment/reward' of employers (see Table 10.2). These include differential systems of contributions and merit systems for firms for sickness absence and employment disability. Another group of measures has been summarized under the heading 'financial punishment/reward of employees'. These include the introduction of an own-risk element for sickness absence and employment disability, and more stricter eligibility criteria for disability benefits. A number of experts said that rewards for attendance would be more effective than any punishment for absence. Several measures concerning the institutions paying out benefits were proposed. These measures were concerned with a greater and more selective control of the Sickness Benefit Act or with its abolition. Other measures were concerned with cooperation and a better division of tasks between GP and social insurance institutions (for example, between GP and social insurance physician) and with the procedure used to support the sick employee (for example, on the first day of sick leave a decision is made about the supervision and support of the employee). In the area of the quality of working life measures were proposed concerning 'social policy' and 'human resource management'. These measures included 'more attention to be paid by firms to sickness absence/employment disability, and more support for sick employees', 'more attention to be paid to the adaptation of work to the abilities and needs of employees', 'more social support for employees', 'career guidance', 'responsibility for working conditions, sickness absence and social policy to be given to management rather than personnel departments and doctors', and 'policy measures directed to older workers'. Measures involving the improvement of working conditions were often mentioned. Such measures are concerned with the field of ergonomics, job content and work pressure. 139

Table 10.2 The 20 measures most often proposed in the areas of social security, quality of working life and provision of care for halving the rates of sickness absence and employment disability by the year 2010 Social security: * introduction of a greater differentiation in premiums paid by firms for the Sickness Benefit Act and the Disability Insurance Act * introduction of a merit system for firms in the Sickness Benefit Act and the Disability Insurance Act * introduction of elements of own risk by employees in the Sickness Benefit Act and the Disability Insurance Act * application of stricter eligibility criteria for sickness and employment disability benefits * a greater and more selective control of the Sickness Benefit Act (or the abolition of it) * abolition of the present division in medical treatment and control (GP vs. insurance physician) * better procedures for the support and guidance of sick employees Quality of working life/ social policy/ improvement of working conditions: * more attention to be paid by firms to sickness absence, employment disability and the support and guidance of sick employees * more attention to be paid to the adaptation of work to the abilities and needs of the employees * more social support for employees * more career guidance * more responsibility for working conditions and sickness absence to be given to management (instead of personnel departments and medical stafO * more policy measures directed to older workers * measures to improve ergonomic problems and job content and to reduce work pressure Provision of (occupational) health care: * better cooperation between occupational health care and the social security institutions, the curative care sector and companies * more research into ergonomics/occupational hygiene * more attention paid to psychosocial problems/stress * more occupational social workers * more care given to specific branches * more prevention instead of cure

140

Concrete measures in the area of the provision of (occupational) health care are directed to cooperation between occupational health care and the social security institutions, the curative care sector and companies. Measures to widen the scope of occupational health care were often suggested. These measures were concerned with such things as research into ergonomics/occupational hygiene, more attention to psychosocial problems/stress, more occupational social workers, more care directed to specific industries and more prevention instead of cure. There appeared to be no differences in opinion between experts from different occupational backgrounds. Looking at the measures that were given top priority, we can make the following observations. The set of measures directed at the improvement of working conditions corresponds with the exploratory scenario of that name. There is also a set of measures directed at occupational health care, which is therefore seen as an important factor in lowering the rates of sickness absence and employment disability. While in the provision of health care scenario an extension of occupational health care was suggested, in the goal-oriented scenario the experts proposed more radical changes in the present occupational health care system. This fits in well with the themes proposed by the experts for a supplementary scenario, where the organization of care in the context of work and health was often named. Out of the list of measures another scenario could be distilled, namely a scenario with respect to the social security. This theme was also mentioned a number of times in the first round as a possible supplementary scenario. The measures proposed by the experts are aimed at halving the rates of sickness absence and employment disability by the year 2010. A number of experts said that this goal was unattainable. It can be assumed, however, that the measures given a high priority, as indicated in Table 10.2, would make a positive contribution towards decreasing sickness absence and employment disability. 10.4

The costs of the proposed measures

The experts found it difficult to estimate the costs of the proposed measures. Out of the 88 experts, only 55 answered the question: 'What is

141

your estimate of the yearly costs entailed in the two measures that you proposed and how should these costs be financed?' Over half the experts (38) believe that the benefits of their proposed measures will be equal to or greater than the costs incurred. The decrease in sickness absence and employment disability would justify the expense involved in implementing the measures. As an illustration of possible cost savings, around 165-200 million guilders (or approximately US $80-100 million) would be saved if the number people who are yearly declared disabled for work were to decrease by one percent. This is equivalent to 750 people per year no longer receiving invalidity benefits. A decrease in the rate of sickness absence from 7.6% to 7.5% would yield a saving of approximately 200 million guilders (or US $100 million) (estimates based on data from CARGO, 1989; Bergsma & Van Ginneken, 1990). The estimates given by the experts vary from a few million guilders needed 'for research on ergonomics and occupational hygiene' to a few billion needed 'to start a programme on the improvement of working conditions based on research, product development and education on work and health in the construction industry'. These costs would be met either by the government or by employers/employees (from a contribution out of wages or from the resources of the social security system. Finally a number of experts feel that a Working Conditions Fund should be set up (financed out of funds from the social security system or from government sources), which could then be used to finance improvements in working conditions, education on work and health and research. Estimates concerning the budget of this fund vary from 50 to 500 million guilders (approximately US $25-250 million) per year. 10.5

Summary

In the seventh scenario, the so-called goal-oriented scenario, the ultimate goal was set at the start and the question was how this goal could be reached. The goal of this scenario was to halve the number of people who yearly become disabled for work, and to halve the rate of sickness absence in the Netherlands by the year 2010.

142

The 88 experts were asked to indicate what concrete measures would be required in order to reach this goal. The measures could lie in several suggested areas. The areas suggested were the quality of working life, the social security system, legislation, the provision of care, financing, education on work and health, scientific research and company fitness programmes. The experts could also propose measures outside these areas. Of these policy areas the area of 'the social security system' was most often mentioned as a high priority area, followed by the 'quality of working life' and the 'provision of care'. 'Company fitness programmes', 'scientific research' and 'education on work and health' were given a low priority by experts. The application of the results of scientific research were, however, considered important. The most important priority measures named by the experts can be placed under the three following headings: measures concerning the 'financial punishment/reward of employers', measures directed towards 'a better social policy inside firms' and measures directed towards 'an improvement in the execution of the Sickness Benefit Act and the Disability Insurance Act'. Measures coming under these three headings were proposed by experts from all six occupational groups. The experts found it difficult to estimate costs. The majority of experts, however, expected benefits to be equal to or greater than the costs.

143

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11

FUTURE PROJECTIONS OF SICKNESS ABSENCE AND EMPLOYMENT DISABILITY

11.1 Introduction In order to obtain as clear a view of the future as possible, a method in addition to the Delphi method was used, namely extrapolation into the future on the basis of data from the past. This method confronted us, however, with the problem of the limited data available. As mentioned earlier in the report, there are few representative statistics on aspects of work and health in the Netherlands. Furthermore the relation between the quality of working life and the health of the labour force has been mainly analysed qualitatively. It is therefore difficult, given the lack of data, to estimate the effects of future developments in the quality of working life on the health of the working population. In spite of this, we shall attempt in this chapter to obtain a better insight into the future by means of projections. In doing so we shall limit ourselves to an exploration of future developments in sickness absence and employment disability as most of the data available relate to these aspects. Projections were made in two ways. First the influence of the state of the economy on sickness absence and employment disability was examined (see § 11.2). Sickness absence and employment disability in 2010 were estimated on the basis of economic data. Secondly the influence of demographic changes was considered (see § 11.3). Projections were made of sickness absence and employment disability for the year 2010, in which the changes in the composition of the working population by age and gender were taken into account. These projections show the effect of demographic developments on both indicators. The results are summarized in § 11.4.

145

11.2 Influence of economic developments on sickness absence and employment disability until the year 2010 The number of yearly bankruptcies of firms in the Netherlands was used as an indicator of the overall financial situation. Data from the Central Bureau of Statistics are available for the last 40 years. There is a striking relationship between the number of bankruptcies and the cases of sickness absence and employment disability, absence and employment disability. This relationship is illustrated in Figures 11.1 and 11.2.

Figure ll.I Rate of sickness absence and number of yearly bankruptcies of firms in the Netherlands (1950 - 1990). Source: NIPG, 1991; CBS, 1989 X 1000

percentage

lOH

52 54 56 56 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 1950 1990 I rate eick. absent.

mm bankruptcies xlOOO

It may be seen from Figures 11.1 and 11.2 that these three variables exhibit a reasonably similar undulating movement, except that the undulations in sickness absence and the number of new people armually made disabled for work tends to preceed similar movements in die number of yearly bankruptcies by five years.

146

Figure 11.2 Number of new people annually declared disabled for work per 1,000 insured and number of bankruptcies of Arms in the Netherlands (1969 - 1989). Source: GMD, 1970-1991; CBS, 1989 X 1000

1969

1989

I deci. disabled work

I bankruptcies. xlOOO

The relationship between sickness absence and employment disability and the financial situation of finns in the Netherlands (measured by the number of bankruptcies) was calculated using correlation coefficients. The correlation coefficient between sickness absence and the number of bankruptcies five years earlier is only 0.08. The relation between sickness absence in any year and the number of bankruptcies in the same year gives a coefficient of 0.48, which is significant. The relafion between sickness absence and the number of bankruptcies five years later gives a coefficient of 0.87 and is therefore the strongest. The same relationship can be observed with the number of new people annually declared disabled for work; there too the relationship with the number of bankruptcies five years later is the strongest (r=0.83) and the relationship with the number of bankruptcies five years earlier negative (p=-0.38).

147

A possible explanation of these results is the following (see Figure 11.3). With a recession in the economy, sales and hence profits fall. This leads to a number of cost-saving measures. Some of these measures would consist of shedding labour via the Unemployment Act, the Sickness Benefit Act and the Disability Insurance Act, as well as reducing the number of supporting activities for personnel and attempting to reduce the number of people in active employment (see also § 11.4). It is also possible that this reduction in the workforce causes a greater workload (and work pressure) on the remaining employees. This in turn leads to more sickness absence and to a greater number of people becoming disabled for work. If the recession continues, some firms will have to close down and file for bankruptcy. Figure 11.3 The sequence in time of the effects of worsening company results on sickness absence, employment disability and redundancy

Redundancy and unemployment

^

Pf Worsening company results M

Sickness absence and employment disability

P|

J

Bankruptcies and unemployment

Worsening company results therefore lead over a period of time to more sickness absence and employment disability and, after a few years, to bankruptcies. An increase in sickness absence and in the number of new people declared disabled for work, according to the data from 1969-1989, precedes an increase in the number of yearly bankruptcies by five years. 148

For the sake of completeness, it should be mentioned that the same kind of calculations as were carried out for bankruptcies were also carried out for annual unemployment rates. The correlation between the annual unemployment rate and the number of yearly bankruptcies in the period 1950-1988 is very strong (r=0.82), and the relationship between the annual unemployment rates and sickness absence and the number of new people declared disabled for work is the same as between bankruptcies and the two indicators of 'work drop-out\ There is no point in showing both analyses: their results are more or less the same. We used the strong relationship (in the last 20-40 years) between sickness absence and employment disability and the financial situation of firms in order to make extrapoladons into the future. Let us assume an economic boom in 2015. The number of bankruptcies in that year could then be equal to that of the 1955-1957 period, in which the Dutch economy prospered. We could however also assume a recession in 2015, in which case the number of bankruptcies in that year could be similar to those in the period 1981-1983, the time of severest recession in the Netheriands since the Second World War. We should add that the number of bankruptcies is also dependent on the total number of firms. What matters in these calculations is the relationship between the number of bankruptcies in an economic boom and that in a recession. We assume that this relationship will remain much the same in the future as it has been in the past 40 years. Using linear regression analysis we can now estimate the quantitative relationship between the economic situation in 2015 (expressed by the number of bankruptcies in that year) and sickness absence and the number of new people declared disabled for work in 2010. Using a representative sample of national data on sickness absence (SVr, 1990), the results are as follows: in a situation of economic boom in 2015 the rate of sickness absence in the year 2010 would lie between 3% and 8% and in a situation of economic recession in 2015 the rate would lie between 11% and 15%. On the assumption of an economic boom in the year 2015, it is estimated that between 5 and 16 new people out of every 1,000 will have been declared disabled for work five years before. On the assumption of an economic recession in 2015, the number of new people

149

declared disabled for work per 1,000 insured would be between 22 and 33 per 1,000. 11.3 Influence of the demographic distribution of the working population on sickness absence and employment disability until the year 2010 The age and gender-specific rates of sickness absence in Figure 11.4 are based on seven-year averages (1983-1989) (calculated with the help of data on sickness absence from NIA and SVR). Figure 11.4 shows clear differences between the rates of sickness absence of men and women. The rate is higher for women than for men in all age categories. Figure 11.4 also shows that older people on average have more sickness absence than younger people. Figure 11.4 The rate of sickness absence of men and women in five age categories in 1990 (based on 1983-1989 data and standardized with the help of the national rate of sickness absence in 1990) percentage

16-24

26-34

36-44 I men

46-64 I

66-64

16-64

1 women

We shall next look at how sex and age are related to employment disability. For the number of new people declared disabled for work per 150

1,000 insured use was made of data ranging over a period of seven years (1983-1989). Women in the 1983-1989 period had a slighfly smaller chance of being declared disabled than men (see Figure 11.5), namely 11 per 1,000 insured as opposed to 13 per 1,000 for men. The older one becomes, the greater the risk of becoming disabled. Figure 11.5 shows that 25 to 26 people per 1,000 insured in the age group 45 to 55 years, and 38 to 39 people in the age group 55 to 65 years, were declared disabled for work. In other words: 3% of people over the age of 45 were declared disabled for work. For younger people (15-24 years old) the figure was only 5 per 1,000 insured. Figure 11.5 Number of new people declared disabled for work, by age and sex categories, based on seven-year average, 1983 - 1989 per 1000 insured

16-24

26-34

36-44 I men

46-64

66-64

16-64

I ..,.1 women

Related to the estimate of employment disability in 2010 is the question of how the relative size of the age categories of men and women will develop up to that year. According to the forecasts of the Central Planning Office (Op de Beke & Arts, 1987) the distribution of sex and age categories will be different in 2010 from that in 1989. Figure 11.6 shows a detailed forecast for the 151

period 1990 to 2010. The percentage of women in the working population wiU increase from (9%+12%+10%+5%+l%=) 37% to (7%+10%+12%+ 9%+3%=) 41% between 1990 and 2010. The percentage of younger people (up to the age of 35) will fall from (9%-»-19%+9%+12%=) 49% to (7%+12%4-7%+10%=) 36% in the period 1990-2010. The percentage of older people in the working population (45-64 years old) will increase from 23% in 1990 to 38% in 2010. Figure 11.6 Composition of the Dutch working population in 1990 and 2010, by age and sex categories, in percentages of total for each year

11990

S « i 2010

in both years: men • women • 100 %

Sickness absence and the number of new people declared disabled for work in the year 2010 were estimated on the basis of these forecasts about age and sex distribution and the ratio of men to women in each age category. The method of calculation used is the following: the figures on sickness absence and employment disability per age and sex category were multiplied by the percentage of working people in each of these categories in 2010 and then aggregated.

152

The results are as follows. As noted, the national rate of sickness absence in 1990 was 8.2. This rate would increase to 8.6% in the year 2010 if one were only to take into account the changes in the age and sex distribution of the working population (i.e. relatively fewer men between 15 and 45 years of age, fewer women aged under 34, more men between 45 and 64 years and more women over 35 years). The number of new people declared disabled for work was 14 per 1,000 insured in 1989. This will increase to 16 per 1,000 insured in 2010 if we only take into account the changes in the age and sex distribution of the working population. The direction of the influence of a changed age and sex distribution on the rate of sickness absence and the number of new people declared disabled is the same: with both indicators there is a slight increase. 11.4 Summary, discussion and conclusions Table 11.1 below summarizes the results of the three projections. We first compared the results of the Delphi study with the economically determined projections. The two extreme economic alternative futures chosen (as indicated by very many and very few bankruptcies) can be compared with the low and high economic growth scenarios of the Delphi study. If we compare the results of both approaches, we can observe the following with respect to employment disability. The experts in the Delphi study expect a decrease of 1 person disabled per 1,000 insured in the year 2010 in the high economic growth scenario and an increase of 1 person per 1,000 in the low economic growth scenario. The size of the changes (1989/1990 in relation to 2010) predicted by the Delphi experts is much smaller (-1 and +1 respectively) than that of the economically determined calculations (circa -4 and +13 respectively). With respect to sickness absence, there is a striking difference between the Delphi results and our own economically determined calculations. The Delphi experts expect an increase in sickness absence from 8.2% to 9.6% in 2010 in the high economic growth scenario and a decrease of 8.2% to 6.4% in the low economic growth scenario. With the calculations based on economic grounds, the results were exactly opposite: an economic boom goes together with a low rate of absence and an economic recession with high absence. 153

Table 11.1

Summary of the results of the Delphi study and of two projections into the future with respect to sickness absence and the number of new people declared disabled for work

Rate of sickness absence

Number of new people declared disabled for work

Present (1990,1989)

8.2

14

(1) Future (2010) according to 88 Delphi experts, given: - high economic growth - low economic growth - average economic growth

9.6 6.4 8.4

13 15 14

(2) Future (2010) given: - favourable economic situation in 2015 - unfavourable economic situation in 2015

3-8

10 (5-16)

11-15

27(22-33)

(3) Future (2010) on the basis of demographic projections for 2010

8,6

16.5

How can we explain these contradictions? One possible explanation is that we only took the influence of the business cycle into account in our calculations. In their estimates the Delphi experts had to take into account not only economic developments, but also technological, demographic and sociocultural developments. This may have led to other results with respect to sickness absence. A more plausible explanation is that, when estimating the effects of an economic recession on sickness absence, the members of the panel gave more weight to such elements as a more stringent control of sickness absence during recession than to other elements, such as the continuous outflow of employees via the Sickness Benefit and Disability Insurance Acts.

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All things considered, it does appear that the economic situation has a large influence on sickness absence and on the number of new people being declared disabled for work. The relationship between the economic situation and sickness absence/employment disability has been examined in other studies as well. On the basis of an empirical study of 85 firms, Smulders (1984) concludes that businesses in a bad financial position - other relevant factors being constant - show a high rate of sickness absence, while firms in a favourable financial situation have a low rate. Kruidenier and Bakker (1985) come to similar conclusions: in difficult times firms tend to lay off personnel via the Sickness Benefit Act and the Disability Insurance Act. Van de Bosch and Petersen (1980) were the first to publish on the relationship between the economic situation and employment disability in the Netherlands. In particular, they introduced the concept of 'hidden unemployment in employment disability', indicating a relationship between economic recession and large numbers of people being declared disabled. Bijlsma and Koopmans (1984) and Vrooman and De Kemp (1990) also conclude that there is a positive correlation between the rate of unemployment and the number of new people declared disabled. They suggest that a reduction in employment opportunities encourages people to make use of employment disability because these benefits are higher than unemployment benefits. The results of our forward calculations based on the economic situation also show a positive correlation between the rate of unemployment and sickness absence/employment disability. Our results are therefore a confirmation of earlier results. What is new, however, is our discovery that sickness absence and employment disability are not only the direct outcome of the difficult financial situation of firms, but also precursors of later bankruptcies and unemployment. If we compare the results of our calculations based on demographic trends with the estimates made by the Delphi experts, the following may be noted. The increase in the rate of sickness absence and in the risk of employment disability until 2010 will, according to of our calculations, be 155

greater than the estimates made by the experts in the medium economic growth scenario. For sickness absence, 8.4% as opposed to 8.6%; for new people declared disabled for woric, 14 as opposed to 16.5 per 1,000. The Delphi experts were asked, however, to take into account developments by age and sex in the working population when making their estimates. The difference could be a result of the Delphi experts' considering other factors to be more important than demographic shifts, such as economic developments and changes in the quality of working life, etc. It is possible too that the experts, when estimating the effects of an economic recession on absence, underestimated elements such as the continuous outflow of employees via the Sickness Benefit Act and the Disability Insurance Act. Aarts and De Jong (1990) recently made the same kind of calculation. On the grounds of future differences in age and sex in the working population (based on the population projections of 1988) they estimated that the number of new people declared disabled for work would increase from the present 14 per 1,0()0 insured to 20 per 1,000, an even higher figure than the 16.5 per 1,000 that we calculated. In conclusion, the future of sickness absence and employment disability in the Netherlands appears to be strongly determined not just by the quality of working life but also by the state of the economy and to a lesser extent by demographic trends.

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12

SUMMARY AND FINAL REFLECTIONS

12.1 Aim and relevance Even in ancient times people tried to predict the future. What mattered then was the outcome of wars, harvests and distant travels. Nowadays we want to know what will happen to the environment, the energy supply, trends in the birth rate and other issues. In the olden days people would scatter twigs on the sand or consult the Delphic Oracle. Today other techniques and methods are used to explore the future in order to plan and to prevent undesirable developments. Why should we want to explore the area of Work and Health? There are a number of reasons. At the end of the 1980s/beginning of the 1990s a spirited social and political debate took place in the Netherlands about the levels of sickness absence and employment disability, which were widely considered far too high. In 1990 the national rate of sickness absence was 8.2% of all available working days, and nearly 900,000 people were declared disabled for work (out of a working population of around 6.5 million). Some contend that this high drop-out rate is related to the poor quality of working life in a number of industrial sectors, instancing such factors as high pressure of work, high work pace, the large number of toxic materials used in industry and the rapid technological changes, with which older employees are said to have difficulty keeping up. Others point to the large demographic changes that are taking place in industry, such as the ageing of the working population and the increase in the number of women who are entering the labour market but failing to find suitable jobs. Finally, some think that the social security regulations in the Netherlands are so favourable that they are open to abuse and misuse. Many people wonder how the quality of working life will develop in the coming decades. Will it be possible to eliminate the harmful effects of working with toxic materials? Will the assembly line continue to exist? Where will the advances in automation lead? All things considered, there

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is sufficient reason for us to concern ourselves with the future of work, health and well-being. The present scenario study is the first of its kind on this subject to have been conducted in the Netherlands and probably also internationally. The aim of the future scenario study Work and Health is to stimulate a public debate about the future of work and health and to give a better foundation to policy proposals. Two questions were formulated which were answered in this study: 1. What are the present factors in the work situation that can cause adverse effects on the health, safety and well-being of the workforce and what is the prevalence of those factors (for the groups at risk) in the working population of the Netherlands? 2. How will the prevalence of the relevant risk factors in the work situation together with the accompanying health effects change in the period up until the year 2010 as a consequence of more or less 'autonomous' developments and of policy measures? The first question was dealt with in the first part of this report (Chapters 1 to 7). The second question was dealt with in Chapters 8 to 11. The answer to the second question drew heavily on material from the Delphi study we conducted. This study consisted of six scenarios which were presented to a total of 88 experts. In these scenarios we considered such possibilities as a period of high economic growth or high government expenditure on the improvement of working conditions. The experts were asked to estimate how the quality of working life, sickness absence, employment disability, and the mental and physical health of the workforce would develop in each of those six scenarios until the year 2010. In the coming sections we shall summarize and discuss the two questions set out above. First we shall discuss the recent past and then we shall look into the future. 12.2 Recent developments in the area of work and health To avoid misunderstanding it is important to stress that we are talking here about the approximately 6.5 million working people in paid employment and not about those who are no longer in paid employment, such as 158

people declared disabled for work and the unemployed, and those who do not receive a financial remuneration for their work, such as housewives. As far as the quality of working life of the official working population is concerned, three types of developments could be discerned in the period 1977-1986 (see Table 12.1). It can be seen that the developments were relatively favourable with respect to typical hindrances in working conditions (vibration and shocks, noise, dangerous and dirty work) and relatively unfavourable with respect to the mental and physical side of work (work pace, relation between education and job content, workload). Little could be concluded about changes in chemical, climatic and biological working conditions and radiation risks because not enough data were available. Table 12.1 Changes in the quality of working life in the period 1977 - 1986 favourable developments

* less exposure to * * * *

vibrations and shocks less exposure to noise less work that is dirty less work that is dangerous better work relations

unfavourable developments

*

less close relation between education and job content * higher work pace * more heavy physical and mental work

no changes

* monotonous work * promotion opportunities * shift work

Table 12.2 shows developments in the health of the working population in the period 1977-1986. It is very noticeable that the health of the working population appears to have improved during this period; there was a favourable development in six of the nine health indicators. Three explanations could be given for this. First, it may be a reflection of the general improvement in the health of the Dutch population. However, research data, such as that of the CBS Health Survey which show that the health of the Dutch population had not significantly improved in that time period, render this hypothesis implausible. 159

Table 12.2

Changes in the health of the working population in the period 1977 -1986

favourable changes somewhat better subjective health fewer headaches less use of medicines lower rate of sickness absence fewer people declared disabled for work fewer occupational accidents

unfavourable changes

no changes

* backache * fatigue * visits to general physician

Secondly, it is possible that the decrease in the above work-related risks has played a role. This explanation is possible, although there were also a number of unfavourable developments in the quality of working life, such as a less close relationship between education and job content and an increase in the workload and work pace. A third possible explanation is a phenomenon that has received little attention up to now, namely the fact that health grounds have increasingly been used as a criterion for selection of the working population in the Netherlands. Research evidence suggests that the relatively unhealthy have left the work force through redundancy, early retirement and employment disability. As a result, the working population became healthier in the 1980s. The latter two explanations appear to be acceptable; it is not possible to provide factual evidence as to which of the two has had the greater influence. Research on this issue would be extremely useful it could throw light on the extent to which 'better work' and 'better employees' have led to better health in the labour force.

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12.3 Differences between age groups and between men and women The previous section was concerned with the quality of working life and the healdi of the average worker in the Netherlands. There are, however, distinct differences between older and younger workers and between men and women which require attention and policy measures. We shall present the particular problems faced by younger workers (younger than 35), older workers (older than 55), men and women below (see Table 12.3). Table 12.3 Main problems in the quality of working life of four demographic groups of workers younger people

a lot of monotonous work no close relation between level of education and job content a lot of work at a high pace a lot of heavy physical work a lot of noise at work many unfavourable climatic conditions of the environment a lot of work in dirty conditions a lot of work in dangerous conditions not much parttime work a lot of shift work

older people

few promotion opportunities

men

a lot of work at a high pace a lot of heavy physical work a lot of noise at work many unfavourable conditions of the climatic environment a lot of work in dirty conditions a lot of work in dangerous conditions not much parttime work many complaints about leadership and consultation

no close relation between level of education and job content few promotion possibilities

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The research material clearly shows that younger people and men in particular carry out work that involves risks to their health, safety and well-being. Young men appear to be the ones that do the 'dirty work' in Dutch industry. The term 'dirty woric' refers here to heavy physical work, work in a noisy, cold or hot environment, in shifts and in dangerous circumstances. The average work situation of women can best be described in terms of an 'opportunity blockade': women cannot use their education in their job and have few opportunities for promotion. It is true that some 'female' occupations (such as those in nursing care) can be descHbed as 'dirty' and 'heavy', but the degree of 'dirty work' is still less than that carried out by young men. Older workers report poorer health than younger people. They suffer more backache and complaints of the musculoskeletal system and also more fatigue and stress. They also visit their GP more often and use more medicines. Finally older workers have a much higher rate of absence and employment disability. The attention of policy-makers, care providers and researchers has therefore been concentrated on this age group (see Bezold et al., 1986). This is justifiable because many in that age group drop out of the labour force. However, if this 'drop-out process' is to be countered, more attention must be paid to the work situation of younger men and attempts must be made to improve that sort of work. It was established in Chapter 6 that, in the period to the year 2010, more older workers and women will have to be employed in the labour force because there will be fewer young people (due to demographic changes), young people will remain longer in education and women with partners and children will want to join the labour force. Industry will find that older workers and women do not wish or are unable to carry out the work that is now being performed by young men. This means that research must be done on optimal ergonomic adjustments, organizational changes and new patterns of working hours in order to enlarge the possibilities of employment for older workers and women (Bezold et al., 1986). The report of the Dutch Scientific Council for Government Policy entitled 'Work in Perspective' (1990) is for a large part concerned with enlarging the labour participation of women and older people. The report recommends an increase in the number of day nurseries and more after school care facilities as a means of allowing greater numbers of women to join the labour force. For older people the following measures are recom162

mended: more part-time work, more part-time early retirement, personnel policy that is more aware of the needs of older people and vocational training specially directed to those returning to work. In this scenario study we have concentrated on age and sex. This does not mean that there are no other groups that have their own particular difficulties. Foreign employees, for example, often work under worse conditions than Dutch nationals. The chronically ill and handicapped also require attention. The Handicapped Workers' Employment Act lays down that employers must undertake reintegration activities for people who are handicapped. Ergonomic improvements, 'tailor-made' jobs, optimal use of individuds' abilities - in other words, a humanizing approach to work are the key concepts here. 12.4 Differences between industrial sectors today and in the future In Oiapter 5 the quality of work in the five industrial sectors in the Netherlands was examined in detail for the period 1977-1986. The most important problems in the work situation in those branches are summarized in table 12.4. If the number of unfavourable factors is used as a criterion, then the quality of working life is worst in the transport industry, followed by manufacturing, construction and agriculture. According to this criterion, working conditions in the service sector are most favourable, although those working in certain of services have particular problems (nursing, education, police, prison staff, bus drivers). It is clear that the information given in the table is based on one approach, namely the frequent or infrequent occurrence of the 'causal factor'. Other approaches are possible. One could also focus this type of 'risk analysis' on the importance of the health effect and/or the size of the 'exposed population'. Such approaches would, no doubt, give a slightly different emphasis to the information in Table 12.4. One may therefore cautiously conclude that policy-makers and care providers should pay particular attention to the manufacturing, construction and transport industries.

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Table 12.4 Overview of unfavourable aspects in the work situation in the five industrial sectors agriculture

manufacturing

construction

transport

services

* heavy physical work * dirty work * vibrations/shocks * few promotion opportunities

* monotonous

* heavy physical work * noise * dangerous work * climate * few prospects * not much parttime work

* mental work load * monotonous work * no close relation between education and job content * work pace * noise * dangerous work * climate * vibrations and shocks * not much partlime work * shift work

* mental work load * management/consultation

* * * * * * *

work noise dirty work air pollution vibrations/shocks management/consultation not much parttime work shift work

The question now arises as to how the problems in the area of work and health in the largest industrial sectors in the Netherlands will evolve in the future. The Delphi study took this question into account. In the Delphi study 88 experts were asked to estimate how the quality of working life of the working population would develop up to the year 2010, in six scenarios. As a by-product answers were also obtained to the question: will the quality of working life up to the year 2010 differ between industrial sectors, or will the developments in individual industries follow the national trend? For 12 of the 28 indicators about which questions were asked in the Delphi study, the future developments in four sectors (manufacturing, construction, agriculture and services) will run roughly parallel with each other, according to the experts. The sectors are expected to follow the national developments with respect to the following indicators: * more work at a high pace * more work that is mentally demanding * less heavy physical work * more opportunities for promotion at work 164

* * * * * * *

more prospects with the same employer more opportunities for joint decisions making about work less work demanding the same posture for long periods less exposure to vibration and shocks more stringent measures to control sickness absence more reintegration activities for handicapped people more stress

16 work and health indicators will show significantly different developments in each of the four industrial sectors up to the year 2010. These 16 aspects have been shown in Chapter 9 in Table 9.4. This table can be summarized as follows. First we see that the future picture of the service sector corresponds the most closely with the national one. This is not surprising since the services represent the largest sector and are therefore weighted heavily in the national picture. The construction industry, according to the experts, differs from the national future picture on a number of aspects. Here, more than elsewhere, there wiU be monotonous work, time pressure, long travelling times to and from work, lack of flexible working hours and no remuneration for the first days of sickness absence. Stiff competition and the need for the flexible placement of workers appear likely to determine the quality of working life in the construction industry. One favourable development expected is that safety measures, including preventive activities directed at reducing employment disability and back complaints, are expected to improve more than average. The manufacturing industry is expected to have a higher than average increase in shift work and in work lacking any close correlation between level of education and job content. The automation of production processes will be a particular factor in this respect. The favourable future developments expected are: less than average monotonous work, a large decrease in noise problems and a large increase in the application of flexible working hours. Finally agriculture. The possibilities for shorter working hours, consultation about work and preventive activities directed towards employment disability are unfavourable for the future in this industry. This is understandable as agricultural firms tend to be small, making it more difficult to apply shorter working hours and institute preventive activities. These 165

changes are, however, necessary. In agriculture very unhealthy work can be encountered where preventive measures (such as effective protection against exposure to pesticides) should be taken. Relatively favourable expectations about the future are: less time pressure, less shift work and reduced exposure to toxic materials. Agriculture is not expected to follow the national trend of a decrease in sickness absence and employment disability; this is probably because sickness absence and employment disability are already low. 12.5 What do the scenarios have in common? It was mentioned eariier that no two of the scenarios predict two totally opposite patterns in the future with respect to all aspects (e.g. an increase in all aspects as against a decrease in aU aspects). The 88 experts apparently consider that a number of 'autonomous key factors' exercise an influence on the future of work and health. By 'autonomous key factors' we mean factors that are free of economic and policy influences. An explanation follows below. In Chapters 4 and 6 we observed that the nature of employment has changed visibly: employment in agriculture and fisheries has decreased sharply, while work in the service sector has risen continuously. Here we have an example of such an 'autonomous key factor' of the quality of work in the Netherlands. We know that the quality of working life is better on average in the services than in agriculture. The quality of working life in the Netherlands is therefore affected by increases and decreases in the sizes of the various branches of industry. Other 'autonomous key factors' which will have an influence on the quality of working life in the future are demographic and cultural developments. Women who want work patterns that are adapted to their needs and who require day care facilities for their children will join the labour force in increasing numbers. This is mentioned by Offerman and Cowing (1990) in their article 'Organizations of the future', about work in the US. They also assume an ageing of the population, a process that is certainly taking place in the Netherlands. This ageing process wiU be accompanied by (implicit) demands for an improvement in the quality of working life. Offerman and Cowing (1990) suspect that employees will increasingly desire more autonomy at work, self-fulfilment/development and a good 166

balance between work and family. These 'norms and values' will lead to demands for an improvement in the quality of working life. So much for the 'autonomous factors' that will influence the quality of working life in the future. We observed at the beginning of this section that no two of the scenarios predicted totally opposite developments in the future. This does not, however, eliminate the fact that the state of the economy and policy measures are of great influence on a number of separate aspects. The favourable and unfavourable developments in work and health estimated for the period up to the year 2010 will be summarized once more (see Table 12.5). We can conclude that the experts consulted were reasonably optimistic about the future of work and health in the Netherlands. The features of working life which the experts on the whole felt negative about were stress-inducing factors (stressors), such as work pressure, work pace, shift work and the absence of a close relation between education level and job content. The impact of these stress-inducing factors on the quality of working life in fact goes to the heart of the policy issues to be expected in the future. If we ignore the increase in travelling time, because this aspect is economically determined (in that the large scale of firms and the market demand that labour be hired where it is required), there remain five characteristics of working life which require thinking about at policy level. Developments in these aspects were expected to be most unfavourable in the high economic growth scenario and least unfavourable in the two policy scenarios (Improvement in Working Conditions and Extension of Occupational Health Care). The experts expect the gap between level of education and job content to widen the most in the low economic growth scenario. The approach to be followed in order to limit the negative effects of high work pressure, high work pace, mentally demanding work and shift work, etc. is clear: improvement of working conditions and occupational health care for everyone. These are broadly the policy measures recommended in the recently published Work Stress Guide Book (Kompier & Marcelissen, 1990) and in the Sickness Absence Guide Book (Smulders & Veerman, 1990). These measures, however, need to be applied in conjunction with 167

other complementary measures, such as a different kind of management and a more intensive social policy. The problem of understaffing can lead to stress, is moreover often determined by external factors, which make internal intervention difficult.

Table 12.5

General future developments in the quality of working life valid for all scenarios

favourable future developments less monotonous work (2) less noise at work less heavy physical work more safety at work (2) more work requiring the same posture for long periods less exposure to vibration and shocks less exposure to toxic material (1) more consultation at work (2) more work with a shorter working week (<35 hours per week) better promotion possibilities (2) beUer prospects with the employer (2) more possibilities for joint decisions (2) more work where prevention of employment disability is pursued more company activities for the reintegration of partly disabled people into the work

unfavourable future developments less close relation between education and experience with job content (1) more work at a high pace (1) more work under time pressure more work that is mentally demanding more shift work (1) longer travelling time required between work and home (1)

Explanatory note: (1) except in the Improvement of Working Conditions scenario (and sometimes in the Extension of Occupational Health Care scenario) (2) except in the low economic growth scenario

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The 88 experts predicted two developments that will be judged positively by some and negatively by others, depending on their social and political standpoint. These were an increase in flexible working hours and stringent control of sickness absence (in all six scenarios). The experts consulted in the Delphi study also gave their opinions about possible future trends with respect to four health indicators. The future developments with respect to sickness absence, employment disability, backache and stress-reactions may be summarized as follows: * the two policy scenarios are favourable for all four health indicators and especially so for lowering the incidence of backache and the rates of sickness absence and employment disability. * low economic growth leads to a slight increase in health problems in three of the four health indicators; the experts believe that low economic growth would lead to a fall in the rate of sickness absence; * high economic growth is neither better nor worse for the health of workers than low economic growth. In an economic boom the experts would expect the rate of sickness absence to increase; * in the other future scenarios (medium economic growth and internationalization) there are no striking developments; the changes in these two scenarios are smaU and not consistent with each other. The title of this section is 'What do the scenarios have in common?' In other words, which future developments are identical in all six scenarios? With respect to the quality of working life, the six scenarios showed similar developments in many respects. With the four health indicators this was certainly not the case; the two policy scenarios showed favourable developments, the three economic growth scenarios less favourable ones. 12,6 The influence of the state of the economy on the future of work In the Delphi study three economic scenarios (high, medium, low economic growth) were presented to the experts, who were then asked to indicate how work and health would develop in those three scenarios up to the year 2010. These results were given in detail in Chapter 9. It is relevant to compare the results of the two extreme scenarios (high versus low growth).

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A number of aspects of work appear to be relatively insensitive to favourable or unfavourable economic developments. This is true of such aspects as working part-time (<35 hours per week) or full-time, working in shifts, working in the same posture, travelling times between home and work, exposure to vibration and shocks and exposure to toxic materials. The experts apparently think that these aspects of work have an independent development, regardless of the level of economic growth. This does not mean that the aspects described above will not change between now and the year 2010 (irrespective of the state of the economy, work pace and part-time work, for example, will both increase greatly), but that the economic climate has little influence on them. Table 12.6 summarizes the aspects that are most influenced by the state of the economy.

Table 12.6 Influence of the state of the economy: aspects of the quality of working life which will be positively influenced by a high rate of economic growth in the future opportunities for promotion job prospects with the employer being able to make joint decisions and scope for consultation about work active reintegration of people disabled for work close correlation between education/experience and job content noise heavy physical work safety conditions at work

'Opportunities for promotion', 'prospects' and 'being able to make joint decisions about work' would all markedly improve in a period of high economic growth (and worsen in a period of low economic growth). Reintegration of people who are partly disabled for work and prevention of employment disability are both measures that are responsive to the state of the economy. If the state of the economy is favourable, then active policy measures are carried out in both areas; if it is unfavourable, these measures receive a low priority or are altogether neglected.

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The same is true of the relationship between education and job content, noise, heavy physical work and safety. All these aspects show a greater improvement in conditions of high rather than low economic growth. For some aspects the opposite is true. High economic growth is accompanied by greater work pressure and more mentally demanding work than is low economic growth. The general conclusion, however, is that high economic growth offers a better quality of working life than does low economic growth. 12.7 Influence of policy measures on the future of work and health In the Delphi study an Improvement of Working Conditions scenario was presented to the experts (where 200 million guilders - or US $100 million - would be made available each year for improvements to and research and information on the quality of working life), together with an Extension of Occupational Health Care scenario (in which occupational health care would be made available to the whole of the Dutch labour force, a measure which would increase total operating costs by some 7(X) million guilders - or US $350 million - per year). The experts were then asked what influence the two scenarios would have on work and health up to the year 2010, assuming average (medium) economic growth. In other words: the two policy scenarios indicate what extra gains are to obtained over and above an average economic growth rate. The results of our study show that both policy scenarios would have a favourable influence on all 28 aspects of work and health, and would be particularly effective in reducing psychological stressors and ergonomic and toxicological problems (see Table 12.7). It is also evident that in both scenarios more active policy measures would be taken with respect to employment disability. The favourable effects of the Improvement of Working Conditions scenario are estimated to be greater than those of the Extension of Occupational Health Care scenario, but - notably - both policy scenarios would greatly improve the psychological and physical health of working people: the experts predict a substantial reduction in stress reactions, back complaints, sickness absence and employment disability in both scenarios.

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Table 12.7 Aspects of work and health which are favourably influenced by both policy scenarios work pace time pressure degree to which work is mentally demanding working in the same posture exposure to toxic materials stress reactions (fatigue/headaches) backache rate of sickness absence number of people yearly declared disabled for work active policy measures with respect to employment disability active policy measures with respect to reintegration of people who are partly disabled for work

An appealing thought is to combine both policy scenarios. It would be practicable, and the policy measures could complement and reinforce one another. Improved working conditions can be better implemented in conjunction with occupational health care; occupational health care has a better chance of succeeding with improved working conditions. The scenarios together cost some 1 billion guilders (US $ 500 million) per year. The effects will, of course, have an overiap and therefore cannot be aggregated. But the benefits to industry and the savings on social security expenditure will probably be far greater than the costs of 1 billion guilders! While both policy scenarios (Improvement of Working Conditions and Extension of Occupational Health Care) cover important policy areas, there are otiier areas which are as if not more important. The area of social security is particularly relevant to our consideration of sickness absence and employment disability (see (3iapter 10). Concrete measures in the areas of social security certainly scored the highest. Improvement in working conditions came second and occupational health care third. Looking back, a 'social security' scenario would certainly have constituted a relevant approach. In the next section we shall go into this in greater detail.

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12.8 How should sickness absence and employment disability be tackled? The present interest in sickness absence and employment disability is remarkable, as both in fact fell sharply in the Netherlands in the 1980s. The frightening spectre of a future with one million people disabled out of a workforce of 6.5 million people has apparently dominated public opinion. In Chapter 11 we presented the results of a number of forward projections for sickness absence and employment disability. Among other things the influence of the state of the economy on the rate of sickness absence and employment disability in 2010 was examined. Our calculations show that financial problems at the level of the firm and a high number of bankruptcies coincide with high rates of sickness absence and employment disability and that, when things are going well financially, the rate of absence and employment disability are relatively low. Or, to put it another way, bankruptcies are preceded by a high level of absence and employment disability, while a low bankruptcy rate is preceded by little absence and employment disability. An explanation for thiscould be that businesses in financial difficulty are likely to pay extra attention to their labour costs and will be more inclined to shed labour through illness, employment disability and redundancy. Only a few years later do the problems of the firm become evident in the form of of bankruptcy. Projections were made to show the impact of the different age and sex distribution of the working population in the year 2010. This different structure will, to a greater or lesser degree, increase the rates of sickness absence and employment disability 'autonomously' in the coming 20 years. The question of how to tackle sickness absence and employment disability was looked at in detail in Chapter 10, where the results of the goaloriented scenario were described. The main three policy areas which the 88 experts considered to be the most suitable for measures to reduce sickness absence and employment disability were the social security system, the quality of working life and (occupational) health care. The specific measures which scored the highest are hsted in Table 12.8. 173

Table 12.8 The 20 measures most often recommended in the area of social security, quality of working life and health care for halving sickness absence and employment disability by the year 2010 Social security: * introduction of greater differentiation in employers' Sickness Benefit and Disability Insurance contributions * introduction of a reward and punishment system for Sickness Benefits and Disability Insurance * introduction of elements of own risk for employees in the Sickness Benefit Act and the Disability Insurance Act * application of stricter admission criteria for sickness and employment disability benefits * greater and more selective supervision of the Sickness Benefit Act (or none at all) * abolition of the present division in medical treatment and control (GP and insurance physician) * better procedures for the support and guidance of sick employees Quality of working life/ social policy/ improvement of working conditions: * greater attention to be paid by firms to sickness absence, employment disability and the support and guidance of sick employees * greater attention to be paid to the adaptation of work to the abilities and needs of employees * more social support for employees * more career guidance * more responsibility for working conditions and sickness absence to be given to management (instead of to personnel departments and medical staff) * more policy measures directed to older workers * measures to improve ergonomic problems and job content and to reduce work pressure Provision of (occupational)health care: * better cooperation between occupational health care and the social security institutions, the health-treatment sector and companies * more research into ergonomics/occupational hygiene * greater attention to psychosocial problems/stress * more occupational social workers * more care given to specific industries * more prevention instead of cure

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The measures cited are the most important in the leading three policy areas. Each of the measures had wide-ranging support, i.e. they were not recommended by only one or two categories of respondents. This fact may facilitate a possible introduction of new measures in the future, although history teaches us that policy measures concerning changes in the social security system are often 'politically loaded'. As to the question of who should be the 'engine' in preparing and introducing such measures, the answer is clear as regards the area of social security. The Ministry of Social Affairs and Employment, in consultation with employers and employees and the social security institutions, such as the Social Security Council, has the main responsibility for the Sickness Benefit Act and the legislation on employment disability. The issue of sickness absence and employment disability was regularly front-page news in the Dutch press in 1990 and 1991, and there was a vehement political debate about how to tackle the problem. The political standpoints were highly predictable. Employers in general pleaded for a tough stance towards employees with a high absence: sickness absence should either hit employees' pockets or result in loss of leave. The unions wanted firms to set up a 'return to work plan' for employees who had been ill for at least three months. Furthermore they felt that firms in which many employees become disabled for work should be financially penalised, while firms employing a lot of handicapped people should be rewarded. The premiums for sickness benefits should go up or down depending on the rate of absence within the firm. Other recommendations from the unions included preventive policy, reorganization of the social security institutions and a greater protection against dismissal for people disabled for work. In the meantime the Scientific Council for Government Policy (WRR) published the report 'Work in perspective' (WRR, 1990), which suggested ways of lowering the rates of sickness absence and employment disability. These suggestions in part overlapped with those made by employers and employees. The central elements in the WRR report with respect to sickness absence, were improvement in the quality of working life, differentiation of the premiums paid by firms for sickness benefits, stricter procedures for reporting sick and compulsory consultation between firm and employee after three months about possible return to work.

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Many elements of the WRR report agree with the results of our goaloriented scenario. A few elements have been worked out in greater detail than in our study. In particular, the WRR emphasizes the social security legislation and regulations. However, little attention is given to improvement in the quality of working life and occupational health care as means of lowering the rates of sickness absence and employment disability. The Ministry of Social Affairs and Employment came into action in 1990 and 1991. Many recommendations directed at lowering the rates of sickness absence and employment disability were made in that period. These have still to be approved by Parliament. Most are intended to be introduced on 1 January 1993. Some of the measures are directed at employers. These are: * the first six weeks of sickness absence will no longer be covered by the Sickness Benefit Act, but by the employer. * greater differentiation in the sickness benefit contributions paid by firms * rewards for firms that take on partly disabled people as employees and penalties for firms that allow employees to become disabled * greater supervision by the Labour Inspectorate of firms with a high rate of sickness absence Other measures are especially directed at the employee. These are: * 70% instead of 100% payment in the first six weeks of illness; * loss of one day of vacation each time an employee reports sick; * new rules for calculating the payment of employment disability benefits. People under the age of 50 who are declared disabled will receive much lower benefits than previously. People under the age of 50 who are already receiving benefits will receive the same money payments as before. People above the age of 50 are not affected by the new rules. * more intensive guidance and support procedures for people who are ill or partly disabled; * better protection against dismissal on health grounds; * broadening of the concept of 'suitable work'; jobs that are offered will have to be accepted, even though the level is below that of the job held before becoming disabled, on pain of losing benefit.

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These are the plans of the Dutch government. We have tried to place the recommendations of the Delphi experts in a sociopolitical context. This should make it clear that many recommendations are 'politically loaded' in other words, some recommendations will be praised by some groups and rejected by others. The introduction of any measure will therefore lead to prolonged political discussions. 12.9 Policy recommendations At the root of the problem of work and health in the future are two main issues, namely labour force participation and mental health. First of all there is the issue of how to contain sickness absence and employment disability within acceptable bounds and also of allowing more people to participate in the labour process. In other words, how is it possible to get women, older people, people in less than good health and people who are partly disabled for work (back) into the labour force and how can one stop the marked selection of employees on health grounds? The second issue is that - compared with the past - physical health problems are now slowly being replaced by mental health ones. We established that a bad match between the level of education and experience of workers and job content, a high working pace and a heavy workload create mental problems and that these same general problems will continue to demand attention in the future. A number of the work aspects mentioned are very sensitive to economic issues, i.e. costs. When the economy improves, one can expect some improvements to take place automatically. When the economy goes into decline, no investments are made in those aspects of working life. This was confirmed by the Delphi study. Other aspects of work can be influenced by policy measures, but the shift from physical to mental problems calls for a different kind of response from policy-makers and care-providers than has been the case in the recent past. How can labour force participation and improvements in the quality of working life, with emphasis on the aspects mentioned above, be stimulated? Of course, legislation, regulation and supervision by the Labour Inspectorate can play a role here. The recommendations made by our experts with respect to sickness absence and employment disability focus strongly on regulation, e.g. contribution differentiation, punishment/reward 177

systems and an own risk element. This type of legislation will possibly lead to greater labour participation in the Netherlands, but not to an improvement in the quality of working life. More can be expected from the welfare demands that have been set out in the Health and Safety at Work Act, from pilot projects, and by issuing making guidebooks, manuals and protocols about stress and well-being to company doctors, personnel departments and works councils, etc. The increasing work pressure is also the subject of discussion in the report issued by the Scientific Government Policy (WRR, 1990). This report suggests that lowering wage costs (i.e. reducing the minimum wage) will enable firms to take on more employees, thus lowering work pressure, stress and problems of employment disability. This is another example of a measure which could be taken jointly by the government, employers and employees. Others contend, however, that lowering wages will lead to the creation of low-paid and unskilled jobs with a limited quality of working life and, we would add, with a high probability of stress and employment disability. The experts in our Delphi study have suggested a number of more specific measures: attention to the problems of sickness absence and employment disability, support and guidance for people who are ill, adaptation of work to the abilities and needs of the employees, social support of employees and career management (e.g. in relation to the large-scale stress problem), etc. Apart from legislation, regulation and supervision, involving employers and trade-unions in the quality of working life is also necessary if firms are to deal with the issues. In their negotiations with employers, trade unions and their members should concentrate less on wages and other financial labour conditions and more on work pressure, optimal labour force participation and investments in the quality of working life. It is recommended that financial resources be made available in order to carry out programmes to eliminate bad working conditions and limit the negative effects of the aforementioned factors. The results of the Improvement of Working Conditions scenario and of the Extension of Occupational Health Care scenario further support the need for such action. Combination of these two scenarios might also be considered.

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So far, we have considered the possible role that government, employers and employees can play in improving labour participation and the quality of working life. What should be done in the area of health care provision? The experts consider the provision of health care (i.e. occupational health care, safety personnel and human resource management) to be a good way of improving the quality of working life and the related problems of sickness absence and employment disability. The experts appears to be saying to the firms: join an institution providing (occupational) health care. The same experts have issued a number of recommendations to the providers of occupational health care in the Netherlands. These are: (1) carry out more work-site research, occupational hygiene and occupational social work, and concentrate on prevention rather than cure; (2) pay more attention to psychosocial problems and stress; (3) direct care to industries as a whole rather than to individual firms; (4) cooperate more with social security institutions, the health care sector and enterprises. In the light of the work problems in the future (typically problems of stress and wellbeing), it may be asked whether the occupational health care services should not radically restructure the expertise of their personnel in line with the problems identified. The accent has been placed here on occupational health care. It should, however, be borne in mind that there is a marked trend in the Netherlands towards the greater integration of the services provided by firms (as a result of the Health and Safety at Work Act), including the safety and well-being of their employees. Such services can provide broadly-based care, are inherently multidisciplinary and by definition meet a number of the requirements outlined above. Government, employers, employees and works councils wiU have to involve themselves intensively in the content, organization and coordination of the desired extension of (occupational) health care. Which expanding firm does not make a prior study of the organization of the new department in question? Research organizations and the advisory boards of the occupational health services could, of course, play a supporting role in this adjustment process. Within the framework of improving labour participation and the quality of working life, social security institutions, employers and employees would be advised to direct their attention to the risk situations and the groups at risk which have been discussed in this report. As far as the 'risk groups' 179

are concerned, younger and female employees deserve special reference. Young people on the whole are expected to tackle the 'dirty work'. The work situation of women - often in part-time jobs - may be described as having 'promotion blocks' (few self-development and promotion opportunities). And in the future, when even more women who have a partner and children will be working, the double workload not only of women but also of men will require greater policy-oriented and research attention. This does not mean that the position of older workers is particularly rosy: many of them drop out of the labour process on account of illness or an accident (only the healthy ones remain in work). It is frightening how little is known about the process of wearing out caused by work and non-workrelated ageing. Research in this area is urgently required. A lot of improvements could be made (especially in the transport industry) to physical and mental working conditions (at present characterised by relatively monotonous, noisy, dangerous work with irregular hours). Finding a solution to these problems is, of course, not simple. Yet making them explicit, as we have done, is already a step in the right direction towards the introduction of policy measures. It would be a pity if all attention were now to be directed at the transport industry, because even in the more 'favourable' industries, such as the service industry, there are smaller sub-groups that deserve attention (e.g. nursing, teachers and the police). It is to be hoped that this report will stimulate discussion and policy on the part of policy-makers in government and in industry. Not only personnel managers, occupational hygienists, company doctors, insurance physicians, safety officers and ergonomists but also - and perhaps especially - managers and members of works councils and the new commissions on Safety, Health and Well-being should play a central role in this.

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ABBREVIATIONS

AAf/Aof AAW ABP AIDS AKT APV BV CAD CBS CNC CNSLD CPB dB(A) EBB GAK GMD HIV LSS MAC MOW NcGv NIA NIPG/TNO OHC PBGC SCP SER SoZaWe STG SVr UV WAO WHO WRR WVC WW ZW

Disability Insurance Funds General Disability Benefit Act Public Sector Employees Pension Acquired Immunodeficiency Syndrome Labour Force Sample Survey Improvement of the quality of workplace Industrial Insurance Association Computer Aided Design Central Bureau of Statistics Computer Numerical Control Chronic Non-specific Lung Disease Central Planning Bureau decibel (using A-filter) Labour Force Survey Joint Administration Office Joint Medical Service Human Immunodeficiency Virus Life situation survey Maximal Allowed Concentration Meaning of Work Netherlands Institute of Mental Health Dutch Institute for Working Conditions TNO Institute of Preventive Health Care Occupational Health Care Periodic Occupational Health Survey Social and Cultural Planning Bureau Social and Economical Council (Ministry of) Social Affairs and Employment Steering Committee on Future Health Scenarios Social Security Council Ultra-violet Disability Insurance Act World Health Organization Advisory Council on Government Policy (Ministry of) Welfare, Health and Cultural Affairs Unemployment Act Sickness Benefit Act 197