Healthy at work, healthy for life: HSC/E goes holistic

Chris Dyer reviews the Government's new 10-year occupational health strategy.

The HSC/E has announced a plan to cut the number of workdays lost due to ill health by one-third over 10 years. The HSC's publication in July of its much anticipated long-term occupational health (OH) strategy for England, Scotland and Wales - Securing health together1 - follows the launch in June of the Government's initiative to inject new impetus into the health and safety agenda, Revitalising health and safety (Employers face major health and safety at work shake-up). The OH strategy adds detail to the targets for OH set out in the Revitalising document. The HSC estimates that, in present-value terms, the gross benefits to society of reaching the headline OH targets could be between £8.6 billion and £21.8 billion by 2010.

Work-related ill health is expensive. Two million people claim they have been made ill through work; the estimated cost to the UK economy is £10 billion a year - three times that of work-related injuries. Each week, 500 people permanently leave the labour market because of work-related injuries or illness, and a further 3,000 move from long-term sick leave to incapacity benefit, 90% of whom never return to work.

The OH strategy addresses the problem holistically, summed up in its slogan: "Healthy work, healthy at work, healthy for life." Announcing the strategy, Bill Callaghan, Chair of the HSC, described it as "an essential, modern approach for the 21st century to a strategy that can embrace the emerging health problems as well as the ones we know. It depends crucially on partnerships that provide a wider view of the meaning of health at work and of the meaning of work for the quality of life."

Partnerships

Like the Revitalising strategy, the OH strategy relies heavily on partnerships: it is trying to involve all those who have an interest in preventing ill health at work, treating ill health and rehabilitating sufferers. These "interested parties" include government departments, local authorities, large organisations, small and medium-sized enterprises (SMEs), workers and their representatives, doctors, nurses, hygienists, designers, ergonomists, human resource professionals and students.

The OH strategy builds on current practice, but acknowledges the consensus highlighted by the consultation that no single factor, be it expert support or legislative compliance, can bring about a major improvement. Instead, it takes a multi-programme approach that can be applied to long-standing and accepted issues like hearing loss or asthma, to problems caused by both home and work activities, and to "newer" preoccupations such as musculoskeletal disorders and stress-related ill health.

The HSC has set up five programmes that will run in parallel:

  • compliance with, and improvement of, OH law;

  • continuous improvement;

  • gaining essential knowledge;

  • ensuring that all the interested parties have the necessary competence and skills; and

  • ensuring that appropriate mechanisms are in place to deliver information, advice and support.

    Targets and goals

    The OH strategy's goals are:

  • to reduce ill health in workers and the public caused, or made worse, by work;

  • to help ill people return to work, whether or not their illness was originally caused by work;

  • to improve work opportunities for people currently not in employment due to ill health or disability; and

  • to use the work environment to help people maintain or improve their health.

    To help realise these goals, the HSC has set headline targets to be achieved by 2010:

  • a 20% reduction in the incidence of work-related ill health;

  • a 20% reduction in ill health to members of the public caused by work activity;

  • a 30% reduction in the number of days lost due to work-related ill health; and

  • ensuring that those off work through ill health or disability are made aware, where appropriate, of opportunities for rehabilitation into work and/or opportunities to prepare for and find work.

    The HSC claims that the targets reflect the scope of the strategy and state what it is designed to deliver, but acknowledges that the HSC and the Government alone cannot achieve them: "The headline targets should be seen as shared aspirations that everyone can work to, and which could inspire interested parties to set their own local targets for improvements in occupational health." The HSC also accepts that it will be difficult to measure some of the targets.

    Despite these difficulties, the HSC believes it is "better to set relevant targets than to target only those things that can currently be measured" and adds: "Although these targets are not always grounded in exact science or precise analysis, the existence of a target is a powerful spur to solving measurement problems." It also recognises that it is possible that some of the measured trends, such as the incidence of work-related ill health, may increase initially as awareness of the issues is raised.

    New structures

    The implementation and delivery of the strategy is being overseen by a Partnership Board, chaired by Bill Callaghan and made up of individuals with particular skills, experiences and access to important networks. The board will report progress to the HSC, which in turn will advise ministers and the board when needed.

    The board is not a representative body and will not necessarily reach consensus. Its role is to produce strategic ideas, to champion the cause, to use its networks to resolve challenges and to take an overview of progress. It will also ensure that sound management principles, particularly evaluation, are used when taking forward the strategy's five programmes of work. The HSC sees evaluation as crucial to success. The board will ensure that the work programmes address priorities and facilitate the meeting of targets: if a particular action is not contributing to the work programmes, it will be modified or stopped.

    Each programme will also be overseen by a programme action group (PAG). The PAGs will identify and outline the detail of what needs to be done under each of the programmes by:

  • considering the priority areas identified by discussions with interested parties;

  • setting targets to take forward the priorities;

  • reviewing what work is currently being done to meet the targets;

  • identifying gaps;

  • agreeing which partners will initiate action;

  • considering advice or guidance forwarded from the board; and

  • preparing progress updates for the board.

    PAGs will facilitate, not manage, projects or actions under a programme. They will consist of leading players in each area; the membership and terms of reference for each PAG will be displayed on the strategy's web site.2

    THE FIVE WORK PROGRAMMES

    The HSC says that the five work programmes are of equal importance. It has already drawn up priorities for each programme, following discussion with interested parties, but the PAGs will decide whether these need to be reviewed or changed.

    Compliance

    This programme intends to improve OH law, such as the HSW Act, the Disability Discrimination Act 1995 (DDA) and the working time Regulations 1998, and compliance with it. The programme aims to secure by 2010 a substantial increase in the number of duty-holders complying with OH legislation.

    Priorities include:

  • introducing agreed new and revised health-related legislation and/or guidance and removing unnecessary legislation;

  • increasing the involvement of health and safety representatives to promote compliance with the law;

  • increasing fines/sentences or introducing other disincentives for breaches of health and safety legislation;

  • providing more information on the economic benefits of addressing OH to help promote compliance with the law;

  • raising awareness of the law within priority groups, such as SMEs;

  • securing consistent enforcement action on OH issues;

  • increasing the involvement of interested parties, such as trade associations, to produce standards; and

  • raising awareness among employers that reasonable adjustments to working arrangements should be made for employees or jobseekers who are, or who become, disabled.

    Examples of activities that will contribute to this programme include the "Good health is good business" campaign and initiatives linked to the DDA to ensure that disabled people do not face unlawful discrimination in the workplace.

    Continuous improvement

    The second programme is concerned with continuous improvement, and by 2010 seeks to promote a culture in which people can work together in innovative ways to address OH. Priorities include:

  • increasing the number of firms whose culture encourages the management of health issues as an integral part of their day-to-day business;

  • increasing the number of partnerships and joint ventures between industry, OH professionals, regulators and others;

  • encouraging government departments and agencies to demonstrate that they are exemplary employers in improving the health of their staff at work;

  • increasing participation in award schemes with an OH component (eg the Scottish "Health at work" award and the Welsh "Corporate standard" for workplace health promotion);

  • increasing involvement of employees or their representatives in decision-making processes and implementation schemes;

  • tackling OH needs at a local level (in both the geographical and company sense);

  • encouraging employers to consider flexibility in the design and management of work so that it is adapted to individuals' needs throughout their working life and so that people are not unnecessarily excluded from work due to ill health or disability;

  • increasing awareness among those who are made ill by work of opportunities to help them return to work. This will increase the numbers of people being rehabilitated at work, and reduce those who are retired on ill-health grounds; and

  • improving the physical and mental health of individuals by using the work environment to promote health.

    Initiatives that result in OH needs being considered at a local level include: the "Health improvement programmes" in England, which draw on the contributions of NHS bodies, local authorities, local businesses, voluntary bodies, community groups and individuals; the "Working well together" campaign in the construction industry; the "Healthy workplace initiative for England", in which a "Back in work" pilot project seeks to raise awareness of the costs of back pain and promote good practice that tackles back pain in a holistic and integrated way; and the "Towards a safer healthier workplace" initiative, which aims to improve the provision of OH and safety services for NHS staff in Scotland.

    Knowledge

    The third programme covers knowledge, aiming by 2010 to secure increased collaboration in order to collect and process the necessary OH data, using a coordinated and standardised approach. Priorities include:

  • agreeing OH data needs (eg for measuring the headline targets, assessment of trends, measurement of exposures, incidence of ill heath and economic cost of work-related ill health);

  • setting up and managing the systems for collecting data;

  • agreeing a coordinated research programme for OH;

  • commissioning and conducting the required research;

  • agreeing standardised mechanisms for collecting and sharing data and research;

  • the partners working together to process the required knowledge; and

  • employers and workers collaborating to decide data needs within individual workplaces so as to help them understand the problems that need to be tackled.

    Activities that will contribute to this programme include a CBI survey on managing OH and the Health of Wales Information Systems (HOWIS) - an electronic service that will allow people in NHS bodies, the National Assembly of Wales and other organisations easy access to information about the health of the population of Wales.

    Skills

    The fourth programme aims to: make a substantial move towards understanding and agreeing the skills (which will not necessarily be formal qualifications) that people require in order to deliver improved OH; to increase the opportunities for people to gain the skills; and to increase awareness of these opportunities.

    The priorities are:

  • identifying the skills required and gaps within the system;

  • developing plans to fill these gaps;

  • ensuring health and safety considerations are delivered as part of the school curriculum (eg under Key Stage 1 of personal, social and health education and citizenship, pupils could learn the basic rules and skills of keeping themselves healthy and safe);

  • making health and safety a component of all relevant management and professional training courses (eg MBAs);

  • producing guidance on competence and on what constitutes a competent person;

  • increasing the percentage of GPs who have a sound understanding both of OH and when they should seek specialist help; and

  • promoting opportunities to gain skills.

    The programme includes the provision of health and safety training by trade unions, such as the Union of Construction Allied Trades and Technicians (UCATT) and the GMB, through contracts with employers.

    Support

    The final programme should ensure that, by 2010, everyone has access to appropriate OH support. This requires the identification of information, advice and other support that people need to be able to contribute to the strategy's targets; the setting up of frameworks to deliver this support to appropriate people; and the raising of awareness of these frameworks and what they can deliver.

    Priorities include:

  • identifying and implementing a report on improving access to OH support from the OH Advisory Committee (OHAC);

  • examining the feasibility of new legislation on the accessibility and availability of OH support in the context of the whole strategy;

  • identifying and "plugging" local gaps in the provision of the support;

  • ensuring that support is provided by professionally skilled people when appropriate;

  • raising awareness of who can provide OH support to communities;

  • developing 24-hours-a-day one-stop shops where people can seek OH information, eg online or interactive, possibly linking with the new Small Business Service; and

  • ensuring that the support matches the needs of the different audiences.

    The conclusions of the OHAC report significantly shaped the OH strategy, and the implementation of the OHAC recommendations should contribute significantly to this programme.

    Work in progress

    The HSC emphasises that the OH strategy is a working document - a beginning rather than an end in itself. It hopes that organisations and companies will contribute to its development by registering projects or actions that contribute to the strategy's goals, either by post or through the strategy's web site, which will contain examples of projects.

    The resources needed to implement the strategy will have to come from many sources, reflecting the strategy's broad approach. The HSC says that to realise the potential savings offered, it is important that "the initial implementation and delivery of the strategy is adequately resourced and supported by all the partners". In terms of financial resources, in addition to its existing expenditure on OH, the HSC is allocating £0.5 million to pump-prime the implementation of the strategy. The amount of other government money available will become clearer as the details of the 2000 spending review for the HSE, Department of Health and other government departments emerge: the strategy links with other government programmes, including Welfare to Work, the New Deal, New Deal for Disabled People and public health initiatives in England, Scotland and Wales. These initiatives are linked by common themes, such as the need to combat social exclusion and to extend the benefits of work to all in a healthier workplace.

    THE NEED FOR ACCESS

    It is unlikely that many people will find much in the strategy to object to. As many of the initiatives are already under way, there is not a great deal currently in the strategy that is new. What is encouraging is the broad approach taken and the recognition that OH should form an integral part of the public health agenda. Collaboration and "joined-up solutions" at government, regional and local level will be essential to achieve the planned results. Government departments, agencies like the NHS and the HSE, and health authorities will need to work closely with employers, unions and community-based projects.

    The OH strategy identifies mechanisms - many involving partnerships - that should be pursued to raise awareness of OH issues, and encourage and facilitate the delivery and use of OH support. But it recognises there is no one solution that will meet the OH support needs of everyone; flexibility will be vital in the mechanisms for delivering the strategy's goals. The delivery mechanisms identified for OH support are intended to give priority to the prevention of health risks at work and the issues that arise from the effects of ill health on work - for example, non-work-related illness compounded by work, and rehabilitation.

    If the strategy is to succeed in removing OH inequalities and improving access to OH support, it will have to improve employer and worker awareness of when such support is needed. Prevention of ill health at work and amelioration of the effects of ill health on work, through rehabilitation for example, are essentially management issues: professional OH support may be required, but this is not inevitably the case. Central to the success of the OH strategy is the need to ensure that employers and managers have access to a point of enquiry that can either suggest solutions or direct employers and managers to the appropriate level of advice.

    Summing up the strategy, Bill Callaghan said: "Securing health together aims to transform OH in Britain and meshes with Revitalising health and safety, our manifesto for wider improvement. A healthier workforce and healthier workplace will benefit all of us - whether employees or employers. In today's society nobody should be denied a job because of disability or other factors. Targeted advice and dedicated rehabilitation programmes will help us deliver this imperative."

    MEASURING THE HEADLINE TARGETS

  • A 20% reduction in the incidence of work-related ill health. "Work-related ill health" means physical and mental illness, disability or other health problems that are caused or made worse by someone's work. As no single source of information is available in Great Britain on the nature and extent of occupational and work-related ill health, the HSE uses different sources to estimate how many people are made ill by work, including the Industrial Injuries Scheme, voluntary medical schemes, household surveys and death certificates. The HSE will continue to use these data sources, and develop others, to measure progress towards this target. The HSC says that to meet the target the dominant, but difficult, factors that are making people ill at work, such as musculoskeletal conditions and stress, will have to be tackled.

  • A 20% reduction in ill health in members of the public caused by work activity. Members of the public can be made ill by work activity, for example by being accidentally sprayed with pesticides, or by exposure to asbestos fibres or hospital-acquired infections. Not all the information needed to measure progress towards this target is currently collected, although data is available in some areas, such as hospital-acquired infections. The HSC says that although addressing all the causes of, or contributors to, ill health to the public by work is important, significant progress towards this target can only be made by identifying and then addressing the major contributors.

  • A 30% reduction in the number of work days lost due to work-related ill health. The figures used as indicators are usually calculated, and presented, for each 100,000 workers. To complement and contribute to other government initiatives, such as A strategy for sustainable development in the UK and the Revitalising health and safety initiative, the HSC has introduced a target to reduce the numbers of days lost due to work-related ill health. Measuring the number of work days lost through illness is a useful measure as it relates to the incidence of work-related ill health, the severity of the ill health and how long an individual is absent from work. This information is collected in different ways and this will need to be standardised so that progress towards this target can be measured. How the data is collected may need to be reviewed.

  • Everyone currently in employment but off work due to ill health or disability is, where necessary and appropriate, made aware of opportunities for rehabilitation back into work as early as possible. Interested parties recognise the importance of early intervention to provide rehabilitation at work for current employees who have been made ill. The provision of rehabilitation is a multidisciplinary function (performed, for example, by managers, OH professionals, doctors and nurses). Opportunities to deliver the elements that make up rehabilitation include return-to-work assessment, physiotherapy, counselling and retraining. This target is the first step in ensuring that those currently in employment, who have been made ill, are rehabilitated back into work.

    This target will be hard to measure as little information is collected on the provision of rehabilitation. Early work will be required to set data collection in place. The HSC accepts that ensuring that everyone is made aware of these opportunities might seem daunting, but it does not want to exclude any individual from being given at least the opportunity for rehabilitation. These opportunities should only be offered where it is clearly necessary and appropriate. Where individuals return to work after mild illnesses of very short duration, offers of rehabilitation might not be necessary. On the other hand, in circumstances where it is unlikely that an individual will ever be able to return to work, offers of rehabilitation might be inappropriate and possibly even distressing. This target is attempting to achieve a change in how rehabilitation is currently viewed and handled in the work environment. Such a change of culture will also help those out of work, who need help, to be rehabilitated back into work.

  • Everyone currently not in employment due to ill health or disability is, where necessary and appropriate, made aware of and offered opportunities to prepare for and find work. Many people currently not employed due to ill health or disability are not given the right support to help them get into work. The HSC wants to change this. It recognises that there will be circumstances where a person may not be able to work and for these it might not be appropriate to offer assistance, but it does not want to exclude any individual from the opportunities open to them. Much work will be required to develop measures for this target. It should not prove difficult to record whether individuals are being made aware of, and offered, opportunities that will help them find work, but it will be more difficult to record whether they actually take up the opportunities.

    MEMBERS OF THE PARTNERSHIP BOARD

    Bill Callaghan, Chair, HSC

    Stephen Hewitt, Policy Director, Department of Social Security

    Michael Richardson, Under Secretary, Director of Employment Policy, Department for Education and Employment

    Pat Troop, Deputy Chief Medical Officer, Department of Health

    Edwina Hart, Assembly Secretary, Finance & Cross-cutting health issues for National Assembly for Wales

    Dr Andrew Fraser, Deputy Chief Medical Officer, Scottish Executive

    Sandra Caldwell, Director of Health Directorate, HSE

    Professor Malcolm Harrington, Chair of OH, Birmingham University

    Robert Baty, Chief Executive, South West Water

    Michael Morgan, Director of Personnel, Northern Foods

    Yvonne Thompson, Managing Director, ASAP Communications

    John Edmonds, General Secretary, GMB

    Brian Brisco, Chief Executive, Local Government Association

    Sara Nathan, journalist

    "GOOD HEALTH IS GOOD BUSINESS"

    The HSE's "Good health is good business" (GHGB) campaign is a five-year programme that aims to raise awareness of OH and increase employers' competence in managing health risks in the workplace. The final phase of the campaign - "Making it happen" - started in October 1999 and runs until March 2001: it aims to build on the earlier phases but with greater emphasis on securing compliance with the law.

    Newly published research commissioned by the HSE3 shows statistically-significant, measurable improvements in OH risk management and changes in employers' attitudes attributable to the GHGB campaign: improvements in about 5% (200,000) of organisations and a change in perceived importance in 25% of organisations can be attributed to the campaign. This suggests that a publicity campaign, combined with seminars and visits, can make a significant contribution towards a target of securing improvements.

    The research compares organisations that are "aware" of the campaign with others that are "unaware". It finds that the likelihood of the campaign coming to the notice of an organisation is linked to size; about one in four small organisations recall seeing promotional material compared with three in four large organisations. The researchers attribute this difference to a lack of dedicated health and safety personnel in small organisations.

    The research finds that there are differences between "aware" and "unaware" organisations of all sizes: the campaign's influence is not limited to large organisations or organisations with health and safety personnel, but the differences in their approach are greatest among large organisations that are "aware" or "unaware".

    Although all organisations report that they have improved health-risk management to a "reasonable" or significant" extent in the past four years, "aware" organisations appear to have a more accurate understanding of health hazards and are more likely to adopt a systematic approach to assessing and managing health hazards and checking the effectiveness of controls.

    The main motivation for improvement among all organisations is a better understanding of OH regulations and how to manage health risks, although the predisposition to make improvements is greater amongst "aware" organisations. The main reason for organisations "not doing more" is that they believe they are "good enough already"; business drivers, or the lack of them, are not explicitly cited as a reason for not doing more. Fewer organisations make improvements because of "business concerns", such as concerns about the costs of ill health; a larger proportion say the reason for making improvements is "moral duties".

    The majority of organisations that are aware of GHGB and have made improvements say that all or some of these were attributable to contact with the HSE and that this contact changed their perception of the importance of health risk: the commonest forms of contact are receipt of literature (20%); visits by the HSE (16%); and advice by phone (14%). Of these organisations:

  • one in three say their view of the importance of health risks was changed by visits by the HSE and one in five by visits by a local authority environmental health officer;

  • one in six changed their view as a result of literature or training by consultants; and

  • half of large "aware" organisations are able to recall campaign adverts, whereas fewer than one in 20 small "aware" organisations can.

    The research finds that the campaign works mainly through educating employers. It has prompted a change in the perceived costs and benefits of health-risk management, but has a greater influence on issues such as understanding regulations, methods of risk management and health risks. Perceived costs and benefits do play a part in prompting improvements, but more are prompted by an increase in an employer's competence.

    Implications for OH strategy

    The GHGB campaign still has the potential to deliver improvements - only one in three small and medium-sized organisations (SMEs) are aware of the campaign. The research suggests that the strategy of educating SMEs should continue through direct communication, such as mailshots and trade journals, and by providing access to health and safety personnel.

    As organisations report being motivated by different factors, the content of the campaign should maintain a battery of messages, although organisations say the presentation of the business case needs to be improved. Some organisations suggest that the business reasons for improving OH risk would be stronger if the perceived possibility of prosecution, especially of individuals, is increased and that this could be achieved by increasing numbers of inspections and prosecutions.

    Organisations also said that promotional campaigns aimed at employers should be augmented by including education on OH risk management in schools, colleges and professional training, and by communicating with employers during business start-ups.

    IMPROVING ACCESS TO OH SUPPORT

    Implementation of the Occupational Health Advisory Committee (OHAC) report4 is an essential element of the OH strategy. The report makes 30 recommendations intended to put in place comprehensive frameworks for OH support that would raise awareness and enable access to such support for everyone that needs it, but particularly people working in small businesses.

    The HSE and Department of Health have agreed a joint action plan to implement the recommendations. This will involve them in working in partnership with a range of people and organisations interested in the health of people at work, such as health authorities, local authorities, NHS trusts, and representatives of small businesses and their employees. The work also forms part of the joint HSE and Department of Health "Healthy workplace initiative". The HSE will work with the devolved administrations in Scotland and Wales, on issues relating to the recommendations.

    The recommendations include action to:

  • ensure that OH is a core issue for health-improvement programmes and primary care group strategies;

  • provide OH training for primary care teams;

  • provide guidance on how to get competent OH advice;

  • pilot a telephone helpline and explore interactive IT systems; and

  • pilot a package to enable small businesses to audit their own health and safety performance.

    1"Securing health together", misc 225, HSE Books, free.

    2www.ohstrategy.net

    3"Evaluation of the 'Good health is good business' campaign'", Contract Research Report no.272/2000, HSE Books, ISBN 0 7176 1805 6, £20.

    4"Report and recommendations on improving access to OH support", available from Angela Wearne, HSE, Rose Court, 2 Southwark Bridge, London SE1 9HS, tel: 020 7717 6225, e-mail angela.wearne@hse.gov.uk, free, and on the internet at: www.hse.gov.uk/hthdir/noframes/access.htm