C
OUR DES
C
OMPTES
Intercompany occupational
health services: a reform in the
making
g
Caution
Summary
of
Thematic Public Report
T
his summary is intended to facilitate the reading and
use of the
Cour des Comptes
report.
The report only commits the
Cour des Comptes
.
Responses by the administrations and agencies
concerned are given in the follow up to the report.
November 2012
Introduction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
1
Organisation of occupational health
. . . . . . . . . . . . . . . .7
2
Service rendered and tasks set . . . . . . . . . . . . . . . . . . . . . .9
3
Reduced State powers
. . . . . . . . . . . . . . . . . . . . . . . . . . .13
4
An operation seeking a new equilibrium . . . . . . . . . . . .15
Conclusion
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Recommendations
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Summary
of the Thematic Public Report of the Cour des comptes
3
Contents
A
lmost all (90%) non-agricultural private sector employees are followed, with
regard to occupational health, by the intercompany occupational health ser-
vices (SSTI -
services de santé au travail interentreprises
) , organized in the
non-profit association (created under the 1901 French Act). Business company direc-
tors are required to be members due to their responsibility for preserving their
employee’s health. Only very large companies have the ability to create their own inter-
nal service, called autonomous services (civil servants have a special singular system
by way of derogation which is not discussed here).
The premiums that companies pay to the inter-company occupational health
services are, from a legal standpoint, a payment in settlement of a legal obligation to
do so. As such, the Court, under Article L. 111-7 of the Code of Financial
Jurisdictions, has jurisdiction to verify them. This point is essential because for over
ten years questions about occupational health have attracted repeated attention by
public authorities; they are the cause of many reports which have been used as sup-
ports for negotiations between social partners; an essential prelude, in this area, to pre-
paring legislative or regulatory reforms. However, with the exception of some scatte-
red data collected by the Inspection General of Social Affairs (IGAS), the operation of
the system itself has never been the subject of a comprehensive study.
Therefore, the originality of the report is to report, for the first time, light on the
subject of the actual service rendered – or not rendered – to companies and their
employees and on the causes of the dysfunctions observed. To this end, documentary
audits were conducted in four regions (Centre, Ile-de-France, Midi-Pyrenees and
Nord-Pas-de-Calais) where six in-depth reviews were conducted in services with dif-
fering size and operations. To this was added the inspection of the General Directorate
of Labour and numerous contacts with the Professional Branch, CISME (Interservices
Occupational Health Centre), specialist universities and social partners represented
on the workplace conditions Steering Committee on Working Conditions
(Conseil
d’orientation sur les Conditions de travail).
Summary
of the Thematic Public Report of the Cour des comptes
5
Introduction
6
7
Summary
of the Thematic Public Report of the Cour des comptes
Cour des comptes
1
Organisation
of occupational health
The French organisation of occu-
pational health is unique in Europe :
in the United Kingdom, employers are
free to choose the means to implement
the obligation of safety that they are
responsible for; in Scandinavia or
Belgium, services are internal to the
company while Spain and Germany
have retained the principle of external
services, entrusted to mutual compa-
nies or professional associations.
However, the French system is
also distinguished by the place that it
traditionally gives to a specialist doc-
tor, the occupational physician, who is
responsible for assuring employers, by
means of medical examinations at the
time of hiring, that «the employee is
medically fit for the work position that
the employer intends to assign to him»
(R. 4624-11 of the Labour Code).
This «insurance related» ratio-
nale at the root of the right of ability
has always coexisted with a tradition of
prevention known as «primary» driven
by social security organisations, social
partners and professional bodies.
These initiatives have enabled the
significant
standardisation
work
undertaken by the public authorities
and the labour ministry to be passed
on to set preventive measures by risk,
sector and occupation.
In addition, since 1970, the
public authorities have also wanted to
promote this orientation in services
then referred to as «occupational
medicine» by including, in the duties
of occupational physicians, a «work-
place activity» and a role of « advisor
to the compagny director or to his
representative, employees, staff repre-
sentatives, social services» (Decree of
March 20, 1979).
The fourth Auroux Law, which
created Committee on safety and
health
at
work
in
1986,
then
European Directive 90/391/EC led to
emphasizing this orientation and
introducing,
within
occupational
medicine,
a
multidisciplinary
approach (ergonomics, toxicology,
etc.). The comprehensive Law of
January 17, 2002, confirmed this
choice by transforming occupational
medicine and its service into « occupa-
Organisation
of occupational health
8
Summary
of the Thematic Public Report of the Cour des comptes
tional health».
Emotion aroused by the asbestos
scandal, the proliferation of occupatio-
nal cancers and suicide occurring in a
professional environment as well as the
declining demographics of occupatio-
nal physicians made implementation
of this development more urgent.
Negotiations were therefore resumed
with the social partners, while some
services, with approval from the admi-
nistration, experimented with new
avenues.
The Court’s review then interve-
ned in the context of preparation of
the Law of July 20, 2011, then the
Decrees of February 2012, mainly
applicable on July 1, 2012. It therefore
provides an assessment of the situation
before the reform but by anticipating
certain effects, from experience already
acquired by the most innovative ser-
vices.
Under these conditions, the
recommendations arising from the
Court’s findings have a highly practical
character. They could largely be inclu-
ded in the contracting campaign ini-
tiated between services, the govern-
ment and occupational diseases and
accidents insurance.
9
Summary
of the Thematic Public Report of the Cour des comptes
Cour des comptes
2
Service rendered
and tasks set
With the Law of July 20, 2011,
providing advice to the employers and
employees became the main task of the
services. It was no longer the sole res-
ponsibility of the occupational physi-
cian, but that of a multidisciplinary
team. However, implementation of the
latter, experimental since 1979 and
mandatory since 2002, has been very
slow. The only available national study is
from 2007 and concludes « can we speak
of effective multidisciplinarity... when a
single person in charge of occupational
risks prevention has to assist occupatio-
nal physicians in 3,592 companies tota-
ling on average 34,279 employees?»
The
General
Directorate
of
Labour did not wish to update the
figures. Studies carried out by the pro-
fession naturally show progress but this
is the result of an addition where a licen-
sed engineer is considered equivalent to
the occupational health assistant, a new
profession whose duties and training are
undefined.
Still largely devoid of the necessary
resources, the practice of multidiscipli-
narity is not yet immune to the tempta-
tion to deploy a part of its activity to
large companies, for charged services
that are within the competitive sector.
This is why the steering role of the
occupational physician must be preser-
ved. However, he faces a shortage of
medical time. Occupational physicians
rarely achieve the objective, set 30 years
ago, of one third of the time spent in
advice and activities in the workplace. In
most departments, the tasks, also essen-
tial, of participating in monitoring
health is relegated to this one-third time
and therefore compromises the time set
aside for companies.
Also, the company record filled
out by the physician is completed for
less than 30% of companies. Yet, it is a
regulatory document that detects risks
and which for most of its content can
serve as supporting the «single risk
assessment document» which each com-
Summary
of the Thematic Public Report of the Cour des comptes
Service rendered
and tasks set
pany director must complete. Failing to
complete it is criminally sanctionable.
If this minimum service is not ren-
dered, it is due to a very unfavourable
medical demography. Despite the efforts
deployed and experiments conducted,
none of the services that the Court has
inspected are able to perform all the sta-
tutory medical examinations that they
are bound to perform, including the
periodic visit even though its frequency
has been reduced.
Source: Cour des comptes according to activity reports - years involved: 2009 and 2010.
10
PST: Occupational Health Centre
[Pôle santé travail]
CMIE: European intercompany medical centre
[Centre médical interentreprises
Europe]
AMST: Occupational health and medicine association
[Association de médecine et de
santé au travail]
CMTA: Intercompany and trades occupational medical centre
[Centre de médecine
du travail de l’artisanat et interentreprises]
11
Summary
of the Thematic Public Report of the Cour des comptes
Service rendered
and tasks set
In the near term, this mandatory
periodic visit should also be rapidly
disappearing, the medical time availa-
ble being now largely consumed with
recruiting examinations, which are
essential
formalities
for
labour
contract validity.
Source: 2010 Labour conditions - Labour Conditions Council (COCT)
The growth of the labour force
automatically multiplies the frequency
of recruitment visits, at the expense of
other activities which, however, are
more
important
later
for
the
employee’s health.
12
Summary
of the Thematic Public Report of the Cour des comptes
Service rendered
and tasks set
Source: Cour des comptes, according to the 2010 working conditions report
Small
businesses
and
their
employees are the main victims of the
various identified deficiencies.
It is in this context that the Law
of July 20, 2011 and its implementing
decrees propose generalization of a ser-
vice project, endorsed by public
authorities at the time of approval, and
related to the priorities that the pre-
vention stakeholders and social part-
ners will have acknowledged, at the
national and local level. Under these
conditions and given the context of
the medical demography crisis, the
activity of the services is expected to
greatly differentiate depending on
local resources and by type of compa-
nies.
The risk of drift exists and this is
why the government has an essential
role to play, despite the limits of its
powers.
13
Summary
of the Thematic Public Report of the Cour des comptes
Cour des comptes
3
The reduced powers
of the Government
Public policy regarding occupatio-
nal health and safety is primarily based
on a work of animation and awareness
of safety and prevention standards and
prevention tools. Occupational health
plans have focused on this aim; mobili-
sation of workplace inspection has
contributed to it; the themes of occupa-
tional health and safety are the main
source of follow up given to its actions.
In this overall plan, organisation of
workplace health and its management
only represents one component of the
system. The human resources that the
government has dedicated to this speci-
fic task, both at the national and local
level, are therefore reduced: less than ten
agents centrally and, locally, a network
of forty regional medical inspectors for
labour and manpower, the MIRTMO,
set in the regional directorates of compa-
nies, competition, consumption, labour
and employment (DIRECCTE).
These limited resources are not
reinforced by the status of MIRTMO.
Since 1947, they have been contracted
under public law. In a context of a shor-
tage of occupational physicians, the lack
of career prospects and unattractive
compensation results in significant
vacancies in positions, 40% as of
January 1, 2012.
In addition, the field of recruit-
ment can be problematic, since these are
occupational physicians, often from the
region’s services and called upon to
return, who are responsible for advising
the regional director of companies, com-
petition, consumption, labour and
employment, including service accredi-
tation policy.
The terms of this accreditation
constitutes a second aspect of the
government’s
weaknesses.
Indeed,
contrary to the law in force for other
joint bodies, the Minister, in case of
refusal of accreditation, is not able to
dissolve the service which, in fact, conti-
nues to operate. This is true of one of
the services audited, which had had no
accreditation since 1996.
The Law of July 20, 2011 does not
14
Summary
of the Thematic Public Report of the Cour des comptes
Reduced State powers
change the situation in this regard but
simplifies the procedure, under condi-
tions that deserve attention. It additio-
nally requires that companies using a
nonaccredited service are now alerted to
the situation, which was not previously
the case the human resources are there-
fore reduced and the sovereign powers
weak.
Under these conditions, until very
recently the administration had not
updated the information system data-
base. Services or occupational physicians
must make annual administrative and
financial medical reports but the matrix
is over 40 years old. The General
Inspectorate of Social Affairs (IGAS)
pointed out the obsolescence as early as
1990, with no effect.
None of the elements that could
attest to the implementation of new
objectives set by the legislator, multidis-
ciplinarity for example, is taken into
account; medical data is not used
although it could be an essential repor-
ting base for monitoring developments
on the state of employee’s health.
In view of these obvious deficien-
cies, the new arrangement resulting
from the 2011 law promotes the deve-
lopment of contracts between the
government, the state pension insurance
find and the occupational health (CAR-
SAT) and the services. In line with expe-
riments conducted on the first occupa-
tional health plan, the contracts envisa-
ged by the administration would only
put forward public health goals without
trying to change the management of ser-
vices by adopting measures to effectively
monitor services rendered to companies,
multidisciplinarity for example, or more
generally, workplace activities, as eviden-
ced by the creation of a record for the
company concerned.
A redesign is all the more urgent in
that in terms of governance and mana-
gement, the Law of July 20, 2011 sets
significant challenges for the services.
15
Summary
of the Thematic Public Report of the Cour des comptes
Cour des comptes
4
An operation
in search of
a new equilibrium
Audits performed have shown the
frequent inadequacy of associative life,
in which, without exception, the leaders
of member companies do little. There is
consequently a risk of governance being
taken over by a small group, family
group or joint group from a closed sta-
tus association.
Faced with these difficulties, the
Law of 20
July 2011 opted for a com-
plex system. The board of directors is
now mandatorily joint and is presided
over by the employer. It is doubled by a
control commission that is also joint but
presided over by an employee.
Despite the virtual absence of asso-
ciative life, this law has also maintained
the key role of the general assembly
which designates employer members,
after, however, a notice of the represen-
tative organisations.
With regards to employees, it has
not favoured participation of employee
representatives on the board of directors
by a compensation system which would
be justified. The result is a system half
way between the associative model and
joint content system.
This new governance will therefore
have to face heavy challenges that weigh
on the management of services. These
have made significant advances, in terms
of ethics, by renouncing in particular
the financing of employer representative
organisations. Certainly, the prevention
of conflict of interests by members of
the Board of Directors through regula-
ted agreements is not always exemplary.
The temptation exists to outsource trai-
ning functions and especially advice to
businesses in commercial structures.
More generally, the special tax sys-
tem for services creates an ambiguity:
legally, inter-company occupational
health services are non-profit organisa-
tions but fiscally they are liable for cor-
porate income tax. Some association
presidents therefore feel it legitimate to
manage them as businesses and be paid
accordingly.
At the initiative of the profession,
many services have launched a quality
approach, proposed by the branch and
which should enable the best allocation
of resources with regards to the objec-
tives chosen by the legislature.
16
Summary
of the Thematic Public Report of the Cour des comptes
An operation seeking
a new equilibrium
However, these positive elements
are not enough. With no change to
resources for a number of services, the
results can no longer fund the necessary
investments and the policy of recruiting
new skills that the Law of July 20, 2011,
requires. The revision of funding
methods, a theme that the Law of
July 20, 2011, did not address, is there-
fore necessary.
In fact, it can be noted that close
to half of the services do not comply
with the legal basis for establishing the
contribution. They determine a payroll
rate (capped) and not a contribution per
capita, by the number of employees to
follow.
The value of the contributions
paid would reach € 1.3 million annually,
according to the Court’s estimates. It is
not known to the administration, which
does
not
require
communication.
However, this mass hides a wide varia-
tion in rates in practice for inter-com-
pany occupational health services, a
variation that is difficult to assess
because, depending on the service, the
contribution tables are not comparable,
with some providing a somewhat flat fee
covering all needs and others multi-
plying additional contributions. The
only value that makes sense is, therefore,
as the profession holds, revenue turno-
ver relative to the number of employees
followed. In 2009 it stood at about € 90,
excluding taxes, per year per employee
followed.
This funding project is what is
now expected for occupational health.
17
Summary
of the Thematic Public Report of the Cour des comptes
Conclusion
The recent law of July 20, 2011 and its implementing decrees have intended to
draw all the teachings of the movement, committed in accord with the European direc-
tives, which grows with the transformation of occupational health medical work: that is,
moving from action directed towards the person and curing (secondary and tertiary pre-
vention) to intervention on the causes (primary prevention). As a somewhat fundamen-
tal overhaul, the Law of July 20, 2011, seeks to remedy the deficiencies found by reinfor-
cing the responsibility of social partners in governance and monitoring of inter-company
occupational health services.
Their operation must now be set on a triple basis, the service project, which
employers and employee representatives present to the board of directors for approval, the
certification granted by the government and, finally, the contracting which integrates the
service, the government, CARSAT and the regional social partners.
In order to overcome the difficulties arising in implementation of the reform, the
Court considers it especially necessary to:
- very quickly relaunch consultation with social partners to revise the obligation of
the systematic recruitment medical examination;
- accord to certification the weight which it should have by giving the Minister of
Labour, in respect of joint procedures, the ability to dissolve a service or place under the
responsibility of a temporary administrator;
- increase the involvement of social partners by entrusting them with the responsi-
bility to set floors and ceilings for the amount of contributions and other rights which the
company must pay to the SSTI in consideration for advice and monitoring of employees.
Recommendations
1) Provide, when approving ser-
vices, particular vigilance to the
objectives selected in managing com-
panies with less than 50 employees;
2) at the same set specific objec-
tives in terms of establishing com-
pany records;
3) prepare a clear doctrine on
the consistency of multidisciplinary
services expected, their duration,
their coordination with funding by
contribution, and the boundary with
activities of the competitive sector;
4) identify, separately from
workplace activities, medical time
devoted to health monitoring;
5) relaunch dialogue in view of
a revision of the recruitment exami-
nation which could be limited to spe-
cific cases;
6) quickly open, at the national
level, for «employee physicians», the
continuing education planned in
occupational medicine.
7) study the possibility of
exceptional measures for obtaining
the title of occupational physician, so
as to counteract the risk of non-repla-
cement, eventually, of one occupatio-
nal physician out of two; for this pur-
pose, consider including procedures
for
reconversion
of
General
Practitioner physicians in practice;
8) study the possibility of inte-
grating regional occupational inspec-
tor physicians into the body of public
health physicians;
9) quickly update not only the
administrative and financial repor-
ting model but also the medical acti-
vity report, by adapting them to the
reforms, including implementation
of multidisciplinary teams;
10) align the intercompany ser-
vices with the laws in force for other
joint
structures
by
giving
the
Minister of Labour, with regards to
joint procedures, the possibility of
dissolving a service or placing it
under the responsibility of a tempo-
rary administrator;
11) taking the opportunity for
contracting to define, in consultation
with all players, quantitative targets
relating to the service rendered to
companies and their employees,
including in terms of initial risk diag-
nosis, therefore company records and
Summary
of the Thematic Public Report of the Cour des comptes
18
Recommendations
19
Summary
of the Thematic Public Report of the Cour des comptes
methods of exercising multidiscipli-
narity;
12) quickly proceed with an
initial operational assessment cou-
pled with boards of directors and
oversight commissions, including in
terms of member absenteeism and
planning, as applicable, simplifica-
tion of the arrangement;
13) align with the existing sys-
tem for the oversight commissions
the right of compensation for mem-
bers of the board of directors and, in
the case of a salaried treasurer mem-
ber, the rights to training;
14) align the fiscal system for
services with the general law of asso-
ciations;
15) undertake, with the social
partners, within the orientation com-
mission on workplace conditions
(COCT), useful discussions for fun-
ding reform which would allow them
to entrust the power to regulate
variations in the contribution and
other rights due by companies to the
intercompany occupational health
services, for comparable services, in
return for membership.