Disappointing response to the Black report
The government could have done more to help and encourage employers in its response to the Black report, argues Howard Fidderman.
On this page:
Helping employers
Business checks
Help for SMEs
Local coordination and challenges
Using existing personnel at work
Impairments need not be barriers
Fit for Work
Access to Work
Helping the health professionals
Qualifying the welcome
The disappearing OH service
The pitfalls of pilots
Recession, what recession?
Box 1: The Black objectives
Box 2: Leading by example?
Box 3: Mental health
Box 4: Help for health professionals
Box 5: A new national health body.
The government's response1 to Carol Black's March 2008 review of the health of Britain's working-age population2 shows it embracing in full or in part most of her recommendations, but stalling on one of the key proposals - the formation of a business-led health and wellbeing consultancy - and watering down a few others. Of the initiatives that have received a green light, some are genuinely innovative and others are already under way, planned or provided for in the Welfare Reform Bill that was published on 14 January. While not as radical or detailed as the government-instigated Black review itself, there is enough in the government's response that, if implemented, will have a significant impact on employers, employees and health and safety professionals over the next few years.
Carol Black's report followed a 2007 call for evidence that elicited 267 replies, six "discussion events" and specially commissioned research. Identifying a consensus around a vision "in which the relationship between health and work becomes universally recognised as integral to the prosperity and wellbeing of individuals, their families, workplaces and wider communities", Black made 31 recommendations to achieve three overall objectives (see box 1):
- the prevention of illness and promotion of health and wellbeing;
- early intervention for those who develop a health condition; and
- an improvement in the health of those out of work - so that everyone with the potential to work has the support they need to do so.
In its response, the government welcomes the recommendations, pointing out that they will help realise a dozen of its priorities, including maximising employment opportunity for all, tackling poverty in later life and promoting better health and wellbeing for all. The government is evangelical about the many benefits of working, pointing out that the employed are generally healthier than the unemployed and that "everyone in working families is likely to live longer, healthier and more fulfilling lives than those in families where no one is in work". The human effects aside, beneficiaries also include businesses, the economy and communities. Black put the total annual economic costs of working-age ill health in terms of working days lost and worklessness at over £100 billion - a figure that excludes the costs of productivity losses that do not involve absence.
HELPING EMPLOYERS
The government insists that while there has been progress on health matters at the workplace in recent years, there is still much to do. "There is", it states, "no clear boundary between safety-related issues on the one hand and health and wellbeing issues on the other. We need to ensure that workplaces support individuals across this spectrum, from identifying and managing risk, through supporting those with health conditions, to improvement in overall health and wellbeing. Only by taking such a holistic approach will employers be able to maximise the benefits to the bottom line that can accrue from addressing health, safety and wellbeing in the workplace." Nor does it exempt itself and the public sector from this approach (see box 2).
Business checks
The government's response to Black states it will work with Business in the Community (BIC) to improve the Business HealthCheck Tool, which helps businesses estimate the costs of sickness absence, turnover and worker ill health and injury, and so, in theory, identify potential savings and returns from investing in health and wellbeing. More than 1,000 organisations have used the tool since its launch in July 2008, and the government claims feedback is "encouraging". The Department of Health has also helped develop an element for Investors in People's assessment tool, The health and well-being framework, which will help businesses address absenteeism. Around 200 organisations have tested the framework, which will soon enter its final pilot stage.
Whether improving the Business HealthCheck Tool is what Black envisaged when she recommended the government "develop a robust model for measuring and reporting on the benefits of employer investment" is uncertain. Questions also hang over the government's commitment to public reporting by employers of their health initiatives; the government's response is merely that it will work with BIC on the latter's initiative to ensure that 75% of FTSE 100 companies report publicly on employee health and wellbeing at board level by 2011. Black, however, had wanted more, stating that "employers" - ie not just those listed in the FTSE 100 - should use the new model to report in the boardroom and the company accounts. The government also appears oblivious to the fact that in 2007 the HSE downgraded the priority of its own initiative to persuade employers to report on core health and safety performance.
Help for SMEs
Black claimed that SMEs experience a disproportionate impact of ill-health absence. Given they also face particular "challenges" in dealing with occupational health (OH) - a lack of time, resources and knowledge, for starters - Black recommended a number of initiatives that the government has picked up on. It promises "further development" of NHS Plus, a network of 115 providers of OH services to NHS staff and to local businesses - particularly SMEs. It reiterates its £20 million capital funding of 11 demonstration sites and promises three further years of funding for NHS Plus. This will allow NHS Plus to test the most innovative ways of offering its services cost-effectively to SMEs and also to work with others to develop further clinical and OH standards.
Much of the success of NHS Plus has been with the bigger SMEs, and the government therefore intends piloting an OH helpline for smaller businesses that will offer access to tailored professional OH advice on individual employee health issues. The government will test fee-paid and free variants of the service for two years from summer 2009, with access to the helpline via local "gateways" set up by local partnerships and business networks. The only details on provision are that it "will offer help when something goes wrong by providing business hours access to professional OH advice for individual employee health issues". Whether this is intentionally excluding a preventive role is unclear, although it bears some parallels with the recommendation of the Anderson Review on government guidance that the government establish a telephone advice service offering tailored and "insured advice" to help SMEs comply with health and safety and employment law.
Regrettably, the government is ambivalent about one of the most fundamental of Black's recommendations - that it initiate a business-led health and wellbeing consultancy service that offers tailored advice and support, and access to OH services at a market rate. The government offers only the SME helpline against this recommendation, saying instead that it "will consider the case for such a service once [it has] evaluated the two-year Workplace Health Connect pilot service" (which is being carried out by the Institute of Employment Studies and was due to report in early 2009) and "considered fully the impact of measures set out in this response [to the Black report]. We will also take account of lessons from advisory services in Scotland (Scottish Centre for Healthy Working Lives) and Wales (Workboost Wales)." Given this timescale, employers should not hold their breath in anticipation.
Local coordination and challenges
In response to Black's recommendation that it help smaller firms establish health and wellbeing initiatives, the government will set up a "challenge fund" in 2010 to assist local initiatives for improving workplace health and wellbeing. The approaches must be innovative and encourage worker engagement. The "particular focus will be [on] practical initiatives for mental health and wellbeing in smaller businesses".
New Health, Work and Wellbeing Coordinators will administer the funds. The government will provide start-up funding for the new posts, which are a response to Black's recommendation that it do more at a local level. The coordinators will be expected to "stimulate action" and offer advice at local levels, particularly in respect of small businesses. The coordinators will also encourage public sector employers to be "exemplars", and work with Regional Development Agencies to engage small firms. They will be accountable to regional directors of public health and work initially through existing public health networks.
Using existing personnel at work
The government emphasises that it has to persuade and help all parties at work to address health and wellbeing issues, and therefore welcomes ongoing work by the HSE and local authorities (LAs) to engage directors. It accepts that line managers have an important impact on workers' health, safety and wellbeing and, to improve their competence, will "disseminate" the principles of good line management, including: encouraging worker participation; motivating the workforce; managing staff who have long-term health conditions or impairments; and addressing short- and long-term sickness absence. The Advisory, Conciliation and Arbitration Service (Acas), HSE, Investors in People UK, Institute of Directors, Chartered Institute of Personnel and Development, Federation of Small Businesses, Business Link and Directgov will all be involved in the dissemination.
The government also agrees with Black that workplace health, safety and wellbeing initiatives "will benefit from an extension of the role of safety and health practitioners and, where present, trades unions and safety representatives". It notes that the HSE "will work with and support the TUC to encourage better involvement and training of safety representatives in health matters. As a starting point, the TUC has issued guidance to their health and safety representatives to promote better health at work." The Institution of Occupational Safety and Health (IOSH) confirmed that it was "pleased to be working in partnership with the government in piloting a new training programme, which could potentially helps thousands of safety and health practitioners play a more active role in the management of health in their workplaces".
IMPAIRMENTS NEED NOT BE BARRIERS
The issues of sickness absence, return to work and rehabilitation have been rising up the safety practitioner agenda in recent years, gaining impetus from the publication of the Black review and from the government's attempts to move people off incapacity benefit and into work. The government's response to Black's recommendations will expedite this involvement, both in getting people back to work and in accommodating a person who may be less than 100% fit at work.
"Everyone," insists the government, "should base their choices and actions on the knowledge that work can promote health and working can help you get better. But there is a gap between the growing body of evidence that demonstrates the positive benefits of work on health and the public perception that work may impede recovery. We need to challenge two commonly held beliefs: that you must be off work to recover fully from illness; and that health conditions and impairments are inevitably barriers to employment."
Half of the 600,000 new incapacity benefit claimants in 2008 were in work immediately before their claim; the government believes that many of these would have been able to remain in work had they received adequate support. To address this, the government will pilot early intervention services between 2009 and 2011, including Fit for Work, psychological therapies and employment advisers in GPs' surgeries.
Fit for Work
Black recommended that the government pilot a new Fit for Work service based on case-managed multi-disciplinary support for patients in the early stages of sickness absence. Her aim, in short, was nothing less than "making access to work-related health support available to all - no longer the preserve of the few".
The government has agreed to pilot the service, bringing together employers, healthcare professionals and social services such as housing, debt and skills advice. It will help all workers who are off sick, including those with mental health conditions, to return to work more quickly than would otherwise have been the case. The government notes that there are many local partnerships that are already acting along similar lines; it wishes to support these partnerships and help develop others and so has set aside funds to "pump prime" local pilots.
Given that there is no "one size fits all", the government is looking for innovative approaches that reduce health inequalities in a community. Many of the "components" are already present and funded, and the government will help ensure that "these are brought together in a seamless service". The bidding process to run the pilots will start in early 2009, with the projects running from later the same year until 2011. The government does not comment, however, on Black's belief that the Fit for Work service "would have to be based in, or close to, primary care".
The government is more hesitant than Black about extending Fit for Work to those on incapacity and similar benefits. Whereas Black recommended the services "should be available once they are established", the government says only that it will consider this once it has evaluated the pilots - in effect, not until 2011 or later.
As part of meeting the recommendation that it should fully integrate health support with employment and skills programmes, the government is instigating a two-year pilot in 12 primary care trusts that will see "the embedding" of employment advisers within the Improving Access to Psychological Therapies programme. Although "poor mental health is the main cause of absence from work" (see box 3), the government believes that "with the right support, most of these people can be productive and fulfilled employees." The project will involve advisers working alongside therapists to help people return to work and point those who are unemployed to JobCentre Plus. It is also extending, by three years, the Pathways Advisory Service, which has been placing employment advisers in GP surgeries since 2005 and allows patients to consult a JobCentre Plus adviser in the surgery.
Access to Work
Many of the government's responses to the Black recommendations around getting people back to work are already under way or heavily trailed. The government reminds employers that the steps for helping a person with a disability remain in work "are often much simpler" and cheaper than they might imagine: its Access to Work programme offers funding towards these costs, for example purchasing equipment or paying for sign-language interpreters. The green paper No one written off proposed doubling the programme's budget of £69 million by 2013/14. The government is also looking at how the programme can better help those with fluctuating conditions; for example, it is funding a MIND pilot to provide a support worker who can rapidly help employees when their mental health deteriorates.
The forthcoming welfare reform white paper will set out details of what the government intends to do about "back-to-work" action plans. The plans were trailed in the green paper and involve the government working with employers to agree early interventions for employees with health conditions that put them at risk of long-term absence. The government will also:
- replace its suite of specialist disability employment programmes from October 2010 with a single programme that has a greater emphasis on job entry;
- continue with its implementation of the Employment and Support Allowance, which replaced incapacity benefits for new claimants from October 2008 and involves a new Work Capability Assessment, as well as a Work-Focused Health-Related Assessment that allows individuals to talk to a health professional about returning to work;
- roll out the Improving Access to Psychological Therapies programme (see above), increasing coverage from one in five primary care trusts in England by early 2009 to 50% by 2011 and 100% "thereafter";
- "commend" the use of self-referral to physiotherapy services, although it advises that it is for local areas to decide whether they want to follow the route of the recently concluded successful pilots; and
- encourage the extension of self-referral to allied health professionals, such as occupational therapists.
Helping the health professionals
One of the most refreshing aspects of the Black report and the government's response is the acceptance that tackling health is a task that goes beyond employers and the HSE to encompass other disciplines such as social security and social services. As important as any, however, are the roles played by health professionals, and Black recommended that they had to recognise retention in, or return to, work as a "key indicator of the successful treatment of working-age people".
The government's response points out that it has already begun putting into practice some of Black's recommendations in this area. Work has commenced on the replacement of the current "sick note" with a "fit note", which will focus on what GPs think a patient can, rather than cannot, do. The government has tested out the fit note with 500 GPs and was planning to consult early in 2009 on implementing Regulations, with the new medical certificate slated to come into effect later this year. In the medium term, the government is still experimenting in Wales with an electronic note and restates its commitment to rolling out an electronic note across Great Britain; it is also considering whether it can launch the fit note and electronic format simultaneously. The British Medical Association continues to soften its stance on the fit note, accepting that the note has "potential", although it "would like to see the findings of [the pilot] evaluation because it's crucial GPs can continue to act as the patient's advocate and don't end up policing the system for the Department for Work and Pensions".
The fit note may be the PR flagship in this area, but the core of the initiatives is a national education programme for GPs that will improve their knowledge of, and advice on, OH issues. Work here is already ongoing with a 2008 Healthcare professionals consensus statement on health at work, which commits signatories to collaborate with government and stakeholders to support patients back into work. The government has piloted a National Education Programme with the Royal College of General Practitioners (RCGP) and will make it available to all GPs from April 2009. It is also working with the RCGP and the Faculty of Occupational Medicine on a competency framework and syllabus on work and health for GPs; the training will be available this year - online and from academic centres. In response to Black's recommendation that the medical professional bodies consider establishing a network of GPs interested in work and health, the faculty, the RCGP and the Society of Occupational Medicine are developing a register of interested GPs and a resource pack to support the training initiatives. Other initiatives are set out in box 4.
QUALIFYING THE WELCOME
Given that the government's response has been generally welcomed, it might seem churlish to be overly sceptical. After all, Black told HSB that she was "delighted with the response": she believes the government has "taken on board" her recommendations and is "committed to action". She was "particularly pleased" with the response on electronic fit notes and Fit for Work initiatives.
And it is not just Black: the Chartered Institute of Personnel and Development described the response as a "watershed"; and IOSH similarly sees it as "positive and comprehensive, heralding a new approach to the management of health and wellbeing". The TUC welcomes the report, too, although arguing that it should have gone further and making the fundamental point that the government needs to focus on stopping ill heath and injuries at work in the first place. Other representative bodies do express some doubts, however: the Chartered Society of Physiotherapy, for example, says the "lack of emphasis on early intervention is disappointing".
The disappearing OH service
Regardless of the positive - and deserved - welcome for the response, there are significant reservations that need to be aired. In particular, the government either addresses insufficiently, or simply ignores, some of the most important parts of the report - particularly those that would have had direct and immediate benefits for employers. Thus, while an accreditation system for OH services and a telephone helpline should help SMEs, Black had envisaged something more substantial - a trial information, advice and consultancy OH service that would aim to increase the coverage of OH support, particularly among smaller organisations. Black was open to this being secured either by the service signposting employers to existing OH services or directly marketing its own. It was also to "link" smaller firms with larger firms that had developed good practice and might offer advice and guidance.
Black based her recommendation on evidence from her review showing that many organisations, especially smaller ones, would use and pay for such a service. The service, she said, should be business- and provider-led because best practice, knowledge and expertise are most advanced in the private and voluntary sectors, and "business is more likely to listen to business than take advice from government". Regrettably, the government doesn't bother to debate this recommendation, merely delaying even a simple consideration.
The government has also ignored Black's recommendation that it consider the use of incentives for employers to support employment of those with disabilities and health conditions; the response - changes to Access to Work and a pilot with a mental health charity, MIND - does not constitute incentives. Linked to this, the government also ignores her suggestion that it review the tax rules governing health, wellbeing and rehabilitation services: employers, for example, incur a tax liability if they pay for the rehabilitation of an injury sustained outside work.
The pitfalls of pilots
There is also a wider issue around the government's tendency to throw pilots and challenge funds at problems. Too often, these have proved to be a tactic for making issues and their advocates go away for two or three years, with "evaluations" reporting so far after the pilot that any restart or expansion would prove problematic. This is the case with two schemes that have extensive experience of helping SMEs with health (and safety) issues: Workplace Health Connect, which offered some of what Black envisages but ended in February 2008 and still awaits publication of its final appraisal; and the Worker Safety Adviser [WSA] pilots, which the HSE wound up in March 2007 despite positive evaluations from the SMEs that were involved. The chair of the HSE, Judith Hackitt, acknowledged the problem when she told HSB in December 2008 that the HSE "needs to be clearer at the start of a scheme like this [the WSA] that it will hand the scheme - and responsibility for funding it - to business".
And, while it is good to seek out and trial the best ideas, there must come a point when - 11 years into power - the government ought to be taking a decision on what is most likely to work and then going with it, not launching ever more limited pilots and challenges. Further, the completion of most of these pilots and evaluations will take place after the next general election, when the political impetus might not be the same.
Recession, what recession?
There are other problems too: the government has published few costings and even fewer budgetary promises. The document pays little more than lip service to the current economic climate and offers no idea as to how all these initiatives fit in a country where the economy is in recession and unemployment is rising. Few employers, for example, are anticipating staffing shortfalls, although the short-term should not dictate long-term planning.
As we noted when Black published her report, whatever the window dressing, the main reason the government requested the review was its concern at the extent and cost of sickness absence and the effect this has on the economy and its attempts to alleviate poverty in the UK. These are laudable objectives, but the government's response also leaves the impression that it is playing a "numbers game" in that it is more focused on getting people off benefits than in helping employers at the workplace. To truly improve the health of Britain's working-age population, the government needs to address both.
1 HM Government (2008), "Improving health and work: Changing lives. The government's response to Dame Carol Black's review of the health of Britain's working-age population", Cm 7492, ISBN 978 0 10 174922 0 (external website).
2 Black C (2008). "Working for a healthier tomorrow: Review of the health of Britain's working-age population", ISBN 978 011 702513 4 (external website).
Box 1: The Black objectives The 2008 Black report set out three objectives:
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Box 2: Leading by example? The government is keen to emphasise that, in addition to encouraging the private sector, it intends putting its own house in order. To this end, it is running 10 pilot health and wellbeing programmes for NHS frontline staff. It is also commissioning a systemic review of how the health and wellbeing of the NHS workforce is supported. This will help prioritise action to improve the whole system, as well as recommend action to enable local delivery. The government believes the wellbeing agenda is "already well-developed" within local authorities, where there have been "notable successes" in sickness absence management, health and wellbeing initiatives (88% of councils have employee wellbeing programmes), use of the HSE's stress management standards (used by 64% of councils), and addressing mental health issues in teaching. Schools should also have access at some point in early 2009 to new web-based resources on mental health and to help staff "identify the real risks in teaching environments and take sensible and proportionate action to address these when working with children and young people"; it is not clear, however, how these will differ from the advice that is already available from the same teachernet source (external website). The government also lists initiatives that are being undertaken by central government departments, including "Treasury supporters" at the Treasury, who are staff trained to help colleagues cope with problems. Existing teachernet resources: www.lexisurl.com/CMBaa and www.lexisurl.com/FS5FC (external website). |
Box 3: Mental health The government has asked Carol Black to chair an independent expert steering group to oversee the development of a cross-government National Strategy for Mental Health and Employment. The strategy will bring employers and healthcare professionals together to tackle issues such as stigma and discrimination and helps meet the recommendation in Black's report that the government review mental health support within current policies and determine the most effective method of assisting people with mental health problems back into work. The government will also:
1 Shift, "Line manager's resource " (external website). |
Box 4: Help for health professionals To help health professionals address occupational health (OH) issues, the government:
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Box 5: A new national health body The government is to establish a National Centre for Working-Age Health and Wellbeing, in response to Black's recommendation that there should be an integrated approach to working-age health underpinned by a sound academic base. "There is," agrees the government, "currently no authoritative body focusing on the issues associated with the health of the working-age population in Britain." The new centre will be an independent body that will fill "critical" evidence gaps by identifying and monitoring data trends, and help to determine the impact of interventions. The centre will comprise an observatory, "encourage" research and create an authoritative source of guidance on evaluation. The government believes that the most cost-effective way of establishing the centre will be within an existing establishment, and is planning on a 2009 start-up. |
