Quel avenir pour la médecine du travail ?

C’est la question, certes provocante, que je me suis récemment posée lorsque, interloqué, j’ai entendu les témoignages convergents de certains gestionnaires des ressources humaines, relatant la quasi-démission, selon eux, de cette profession face, notamment, aux demandes des agents en matière de reclassement pour inaptitude physique.

Laconiques et lapidaires dans leurs courriers, certains médecins du travail se borneraient à reprendre mot pour mot les souhaits de reclassement des agents, quelque puisse être le caractère légitime et compréhensible de ces derniers – là n’est pas le débat -, sans faire référence à un quelconque problème de santé et sans aucune motivation.

Ces témoignages sont l’occasion de revenir sur les missions du médecin du travail qui figurent, dans la fonction publique hospitalière ((dont il faut rappeler que la mise en place au sein de la FPH remonte aux années 1960)) , aux articles R. 242-1 à R. 242-24 du code du travail, dans sa partie réglementaire, et qui détaillent les modalités d’organisation et de fonctionnement du service de médecine du travail dans un établissement de santé.

A lire la liste des attributions du médecin du travail figurant à l’article R. 242-11, il apparaît clairement que le législateur a souhaité faire de ce dernier un acteur central de la prévention par la mission de conseil qu’il remplit auprès du chef d’établissement, des personnels et de leur représentant.

Pour mémoire, ses champs de compétence sont les suivants : 1° l’amélioration des conditions de vie et de travail dans l’établissement, 2° l’hygiène générale de l’établissement, en particulier l’hygiène alimentaire et des installations sanitaires, 3° la protection des agents contre l’ensemble des nuisances et notamment contre les risques d’accidents du travail, d’utilisation de produits dangereux ou d’exposition à ces produits, 4° les aménagements relatifs aux postes de travail, notamment en ce qui concerne le travail de nuit et le travail par équipes, 5° l’éducation sanitaire du personnel en rapport avec l’activité professionnelle, 6° les nouvelles constructions ou les aménagements de locaux anciens, les modifications de l’organisation technique du travail du personnel.

Il faut être conscient du rôle de sentinelle, de veille, de conseil du médecin du travail vis-à-vis de l’employeur public comme du personnel et de ses représentants. Par la nature et la diversité de leurs activités, les établissements de santé sont exposés à des risques spécifiques qui doivent attirer l’attention du médecin du travail.

Quelques exemples vécus ou entendus par votre serviteur peuvent, à ce titre, être évoqués : la violence stupide des compagnons des parturientes musulmanes à l’égard du personnel médical et soignant, le harcèlement moral dans un contexte professionnel favorable à ce genre de dérives ((on se reportera à un précédent billet sur la question)), l’alcoolisme dans les filières techniques, la maltraitance dans les services à l’égard des personnes vulnérables, la présence d’amiante dans des locaux parfois vétustes, etc.

Le médecin du travail tient toute sa place au sein des établissements de santé et ne doit être ni le porte-plume des agents ou des syndicats ni l’acolyte du directeur d’établissement, ce qui pose la question de son indépendance. On touche ici à l’ambivalence de la position du médecin du travail qui se doit être bien maîtrisée.

Deux garanties fondent, à mon sens, son indépendance : le code du travail et le code de déontologie.

Son indépendance est en effet consacrée, en quelque sorte, par le code du travail, à travers sa compétence professionnelle, son mode de recrutement, sa capacité à soulever des questions, même celles qui fâchent, à identifier les problèmes et à en prendre la juste mesure, et bien entendu et surtout à proposer des solutions.

On oublie parfois que le médecin du travail est avant tout un médecin, donc une profession soumise à un code de déontologie, comme tous ses confrères, à un Ordre des médecins, et ce sont ces règles qui guident son comportement, ses décisions et ses jugements.

A travers la période d’affiliation des établissements de santé à un service de santé au travail, le médecin du travail doit, pour être efficace, agir dans la durée et apparaître comme un « préventeur », comme une institution de prévention des risques professionnels (IPRP), préalable utile et nécessaire avant le recours à des tiers tels que l’inspecteur du travail et le comité d’hygiène, de la sécurité et des conditions de travail (CHSCT).

Il n’en demeure pas moins, pour autant, que la réalité est parfois tout autre.

Le Conseil économique et social (CES) nous l’a récemment rappelé à travers son avis du 27 février 2008 portant sur l’avenir de la médecine du travail, et dans lequel il pose clairement la question de la capacité de ce dispositif original à répondre aux enjeux de la santé au travail, interrogation renforcée par l’extension des formes atypiques d’emploi et le vieillissement de la population active, cependant que le corps des médecins spécialistes du travail affronte une crise démographique profonde.

Le CES préconise plusieurs actions pour une nouvelle organisation de la santé au travail axée sur le service de la prévention et de la qualité des parcours professionnels. Ses préconisations tiennent en plusieurs points : 1° fixer dans la loi les missions des services de santé au travail, 2° renforcer l’efficacité de l’action du médecin du travail, 3° mettre en adéquation le financement et la gouvernance avec les missions, 4° créer un véritable réseau de la santé au travail, 5° maîtriser la contrainte démographique.

Le 4° attire l’attention dans la mesure où le Conseil propose des liens entre la médecine de ville, la médecine du travail et la médecine hospitalière, dans le respect du secret médical et dans l’intérêt du suivi de la santé des salariés et de la prévention des risques. Selon le Conseil, une réflexion pourrait être engagée en ce sens

« quant aux moyens de favoriser les échanges entre les deux volets de la médecine, en les formalisant. Un volet spécifique « expositions et risques professionnels » du Dossier médical personnel (DMP) pourrait être mis en place. Lui seul serait accessible à l’ensemble des médecins du travail tout au long du parcours professionnel et pourrait être diffusé aux autres médecins. Son unique objet serait d’assurer la traçabilité des risques professionnels et des expositions et de permettre des échanges sur les conditions d’emploi et de travail des salariés dans un souci de cohérence du suivi. »

Le Conseil suggère une réunion exceptionnelle de la conférence tripartite sur les conditions de travail, les modifications législatives et réglementaires indispensables, l’inscription d’objectifs dans la négociation de la convention d’objectifs et de gestion de la CNAMTS et les évolutions concernant le financement et la gouvernance au cours de l’année 2009.

Reste à savoir si cet avis sera suivi d’effets, dans un contexte où la médecine du travail fait débat, au même titre qu’un risque psychosocial dont l’Institut national de recherche et de sécurité pour la prévention des accidents de travail et des maladies professionnelles s’est récemment fait l’écho : le stress au travail.

Omar YAHIA

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