Securing health reloaded

Chris Dyer takes an overview of suggestions for the development of the HSC's 10-year occupational health strategy.

Since its launch in 2000, the HSC's long-term occupational health strategy has had a low profile, despite the fact that, of the 40 million days lost in 2001/2 to occupational ill health and injury, 33 million were attributable to ill health.

Nevertheless, work has been going on with the aim of meeting the HSC's 2010 targets set out in the strategy document, Securing health together1 (Healthy at work, healthy for life: HSC/E goes holistic ):

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

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

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

  • Half of the improvement is to be achieved by the mid-point of the strategy, April 2005.

    A plan to reach the targets has been developed, based on five programmes of work: compliance, continuous improvement, skills, support and knowledge. The HSC set up action groups to look at how these programmes could be achieved. These groups were different from the HSE's usual contact with stakeholders in that the members did not represent interest groups but were chosen as informed individuals with a good grounding in the occupational health (OH) community. The groups had no budgets and were left to meet the priorities set out for each programme as they saw fit. All the groups have now finished their work and have reported on their conclusions2. These were presented at an HSC workshop, "Changing gear: delivering on the promises of Securing health together" held in November 2003.

    Traditional interventions have been less effective when dealing with health than when dealing with safety, with gains in occupational health lagging behind. The focus in occupational health has changed in recent years from the "traditional" areas such as chemical exposures and noise to "new" issues such as stress and musculo-skeletal disorders. There is also a greater emphasis being placed on rehabilitation. The new HSC consultation on Strategy for workplace health and safety for 2010 and beyond (HSC heralds health and safety shake-up ) picked up themes from Securing that re-emphasise the need to do more to address health issues. Taken together, the reports of the programme groups offer models and actions that could be the future for the development of OH in Britain.

    Compliance

    The compliance programme action group looked at the need to improve health and safety law in relation to OH through amendments or new legislation. It also examined compliance with the existing law and was aiming substantially to increase the number of compliant duty-holders. Its report gives details of work in six areas.

  • Increasing compliance through the involvement of health and safety representatives. The group felt it was crucial to improve representatives' status in the workplace, which could be achieved through better educational opportunities and, in particular, through the promotion of body-mapping techniques (see box 1).

    The group believes that body-mapping needs to be promoted with OH professionals as a valid and useful technique so that safety representatives' efforts are well received in companies using occupational health services.

  • Disincentives for breaches of legislation. The group concluded there is not enough robust evidence about what does and doesn't work. The HSE is funding a research project on levers for promoting compliance with health and safety law, which is due to report at the end of 2004. The group concluded that while there might be a case for making the importance of OH more specific in legislation, this needed to be tied in with better support mechanisms.

  • Promoting compliance by stressing the economic benefits. The group decided to look at three specific routes that could be used to evaluate potential OH benefits: the procurement process for suppliers and contractors; corporate social responsibility and fund management for investors; and the uptake and use of costs information already available.

    A project has started involving United Utilities, South West Water and the HSE to explore the health management capability of companies supplying goods and services. Its mission statement is: "To purchase from a supplier that does not protect the health of its employees is not socially responsible, is ultimately more expensive and risks business continuity." The work is in its early stages.

    In July 2003 the HSE published two reports on the extent of public reporting of health and safety by large companies and on the health and safety leadership given by boards and directors (HSC sees safety as society's cornerstone ). The HSE is developing a health and safety management index; its launch is expected in Spring 2004.

    The group found only one report that set out ill-health costs in an industry and promoted the commercial case for better management3.

    This work has been used in various places, including Revitalising health and safety
    (Employers face major health and safety at work shake-up ) and Securing, the HSE's ready reckoner for costing health and safety failures in business (The "ready reckoner" ), and in Revitalising health and safety in construction work (HSC sees safety as society's cornerstone).

  • Securing consistent enforcement on health issues. The group thought there was a need to increase inspectors' health knowledge so that they can take appropriate enforcement action. Work is ongoing on a programme that includes training events, website materials, the inclusion of OH in enforcing authority priority programmes, and a review of the enforcement management model used by inspectors when selecting the appropriate level of action.

  • More involvement of interested parties, such as trade associations, in producing standards. The group set up a project to define what makes good practice and when it is needed. This is being codified for authors of standards. An example of the HSE collaborating on producing good practice guidance is its work with the Disability Rights Commission on sickness management and rehabilitation.

  • Raising awareness of the law among priority groups, such as small firms, and raising awareness among employers that reasonable adjustments to working arrangements should be made for employees or job seekers who are, or who become, disabled. The group believes there are opportunities for the Department of Work and Pensions, the HSE and the Small Business Service together to develop a communication strategy for the aspects of the Disability Discrimination Act coming into force in 2004.

    Knowledge

    The knowledge programme action group set out to investigate getting essential knowledge on occupational health. Its programme encompasses promoting the collection of data and using the material to move other parts of the strategy forward and monitor its success.

    The ill-health targets, which feature in both Revitalising and Securing, present challenges for progress measurement. Most importantly, except in the few instances where a disease is directly and solely attributable to a specific occupational exposure, it is inherently difficult to decide whether an individual case of ill health is attributable to work causes.

    The group's conclusions went into the HSE's report on progress measurement towards the
    ill-health targets4 (see box 2).

    Continuous improvement

    The continuous improvement programme aims to promote a culture that allows people to work together in innovative ways to address OH. The action group decided to set its proposals within a model that describes where an employer or employee stands on an "escalator" for continuous improvement in OH and safety culture. Companies, groups of employees or individuals are divided into three categories on the basis of the development of their culture: those who are not interested at all; those who simply comply with requirements; and those who are enthusiastic advocates. The three categories are set in a matrix against a description of: what drives those in that category to achieve that level of performance; what distinguishes those in the higher-achieving categories from those in the lower ones; the likely perceived issues for each category; and the things that need to be done to progress to the next level (see box 3).

    The continuous improvement group concluded that the use of the matrices facilitates the analysis of the category that an individual or employer falls into and helps to identify the drivers, issues and needs. Once these are known intervention approaches can be planned and management priorities identified. The group acknowledges that this approach is not an immediate solution to all occupational health and safety problems, but believes that it may help to select the right tools at the right time.

    The group also compiled a directory of award schemes related directly to OH and safety or to business management with a health and safety component. Taking part in a scheme encourages companies to improve and to learn about OH as a tool for continuously improving their performance. The directory identifies the important criteria for award schemes and provides a non-definitive list of British schemes.

    Skills

    The skills programme aims to make: a substantial move towards understanding and agreeing the skills that people require to deliver improved OH; to increase the opportunities to gain these skills; and to increase awareness of these opportunities.

    The skills programme action group did not think skills were the first priority in implementing Securing - more important is a much greater awareness of OH issues throughout the population.

    Nevertheless, the group thought that the need for skills would emerge from greater awareness, and from regulation and policy changes, better systems to track sickness absence costs and causes, and from the national occupational health support and rehabilitation service recommended by the support programme action group (see below).

    The group believes that ambitions for better services should be seen in the context of a shortage of trained medical professionals and an overstretched NHS that struggles to provide effective OH support for its own employees.

    The group talked about skills in three ways:

  • generic or "key" skills;

  • skills that are transferable or can be acquired by the general public; and

  • expert skills gained through specialised study and qualifications.

    The group concluded that generic skills, such as the ability to find and interpret information, communication and negotiation skills, self-confidence and so on, were vital, but to contemplate addressing their provision was an impossible task. Providing programmes to develop these skills was, it thought, the responsibility of others.

    The main transferable skills are:

  • the ability to analyse the working environment (work design as well as hardware) and to effect change;

  • the ability to detect early the signs of ill health in oneself and others, and then to find and interpret information and know when and where to seek help; and

  • for employers and managers, skills in risk assessment, policy formulation and communication, evaluation, and in judging when and where to refer for help.

    The group thought that much of the framework for the acquisition of these skills was already in place, although management, health and safety, safety representatives and first aid courses could be altered to give greater emphasis to OH issues and that this would be effective and economical.

    The group agreed that the supply of occupational health expertise is critical to the effective implementation of Securing and that access to occupational health support in British companies is limited. The most pressing need was thought to be for intermediate skills for generalists and experts. For generalists the proposed Occupational Health Technician qualification, which would range from Vocational Qualification level one to diploma level, was supported as a cost-effective means of increasing the critical mass of OH expertise.

    For experts, the group was concerned with the structure of intermediate-level qualifications, such as those for OH nurses, and with the availability of training for other intermediate health professionals, such as nurses working in OH who do not have an OH qualification. The group thought that opportunities should be increased and progression routes made clearer.

    The group also lamented the lack of hard evidence to support a campaign either to increase awareness or skills. It thought that the HSE's funding was insufficient to allow it do the research needed and believes that without this being addressed it is hard to see how Securing can be delivered.

    Support

    The aim of the support programme is to ensure that everyone has access to appropriate OH support by 2010. The programme action group envisages a minimum level of service
    that integrates OH, safety, rehabilitation and job retention.

    The service's objective will be to maximise the functional capacity of individuals, the organisations they work in and the wider economy.

    The proposed structure is intended to be applicable nationwide. Its establishment as a national organisation is not expected to take place in one go, but to grow from existing regional, sector and other support services. The critical element in the structure is that services that provide support are accessed through hubs. These hubs should have a common identity, a link with a national centre of excellence and provide a set of core services.

    The hubs will not be identical, as each will need to maximise access to the population it serves. An individual hub might serve a local community, an industrial sector or any other group with a common need. The national support structure needs multiple access points so that everyone has access to the OH, safety and rehabilitation services they need.

    The baseline assessment provided by hubs may find that a client has a problem that needs: specialist advice, such as assessment of a complex risk; technical expertise, such as the design of bespoke ventilation; or use of an ongoing service, such as physiotherapy. The hubs will have links to a core of experts, whom they would consult for assistance for their clients, and would be able to search for less commonly needed expertise through the centre of excellence.

    The national centre of excellence will ensure that the hubs provide common core services to a common standard, that there is appropriate expertise and development of new approaches to support continuous improvement and that there is a strategic overview at the national level of access to support for OH, safety and rehabilitation.

    The future

    The HSE is now discussing internally how Securing should develop from here. The HSE's hope is that the individual members of the programme groups and other stakeholders can be combined into a "virtual" group to take the work done forward.

    As HSB went to press, the HSC was meeting to consider a paper on the future of Securing at its December meeting that takes into account how the project fits in with the HSC's consultation on its recent strategy document.

    It is unlikely that there will be any new money to fund Securing, although the needs of the project will be represented in the HSC's next bid to government for funding.

    It may be that if Securing is to realise its potential, funds will have to be found from within existing budgets.

    Chris Dyer is editor of HSB and a journalist specialising in health and safety.

    1 "Securing health together", free at www.ohstrategy.com/about_strategy/strategy_home.htm.
    2 www.hse.gov.uk/campaigns/securinghealth/main.htm.
    3 "The Frank Davies project: health protection and accident prevention as business imperatives in the water industry", R Gwyther, South West Water, free at www.water.org.uk/index.php?raw=3049.
    4 "Achieving the Revitalising health and safety targets: statistical note on progress measurement", free at www.hse.gov.uk/statistics/statnote.pdf.


    BOX 1: BODY MAPPING

    Body mapping uses two large outlines that represent the front and back of a body. Workers who are doing similar jobs are supplied with labels or pens to mark the body maps where they think their job is making them sick or hurt. Different colours can be used to represent different health effects - red for pain or soreness, black for stress and so on. As the maps are marked, each worker explains why they marked each particular place. Notes can be kept around the edge of the map.

    Different jobs tend to show different, specific patterns. For example, professional drivers might produce a map that highlights the lower back (from sitting and whole body vibration), the knee and wrist (from gear changes) and on the stomach (digestive problems from inadequate meals and meal breaks).

    Different groups from within the workplace can compare completed body maps to see how reported problems differ between jobs and which problems are likely to be caused by the job. Body mapping can help indicate whether a problem is individual or applies to a category of workers.

    Source: Hazards, www.hazards.org.

     


    BOX 2: TOWARDS ILL-HEALTH TARGETS

    The HSE identified five criteria for measuring progress towards the HSC's ill-health targets.

  • Progress should be measured separately for different diseases, using the most appropriate data sources for each (HSE names high health hazard industries).

    • The HSE's existing sources of occupational health statistics are of five main types: household surveys of self-reported work-related illness (Work-related ill health 2001/02); voluntary reporting of occupational diseases by specialist doctors in the Health and Occupation Reporting network (THOR - formerly the Occupational Disease Intelligence Network); new cases of assessed disablement under the Department of Social Security's Industrial Injuries Scheme; statutory reports under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995; and occupational lung diseases recorded on death certificates.

  • The existing data sources should be refined (by estimating the effects of raised awareness, for example) and new sources developed (such as workplace-based surveys), to meet the needs of progress measurement.

    • The development of a fully HSE-owned workplace-based survey is under way. The intention is that by the mid-point of the strategies, the HSE will have significantly improved its statistical apparatus while retaining links with the existing system so that the two remain comparable.

  • Data from the various sources should be integrated to produce an overall judgment about progress against the targets, for individual diseases and in aggregate.

  • Diseases with long latency periods between exposure and health outcome should be included in the targets, but should be separately identifiable.

  • For ill health, a progress report each autumn will present a judgment based on data from all the sources available at the time; this will include new data from THOR (every year) and SWI surveys (less frequently).

    • The latest update on progress against the targets is included in the Health and safety statistics highlights 2002/03 (see Revitalising: another year, another blank ).

     


    BOX 3: DRIVERS, DIFFERENCES, ISSUES AND NEEDS

    The drivers for each of the categories are different. For example, fear of enforcement, insurance and costs often motivate those who are just considering what OH actions
    they need to take, whereas for the advocates category, where standards are already in
    excess of the legal standard, a desire to excel may be a more important driver than fear
    of enforcement.

    The factors that distinguish between categories need to be identified so that the members of each category can progress and so that change can be monitored and success recognised.

    For each category, there are issues or hurdles that prevent progress. If these are identified they can be overcome, otherwise they can halt improvement.

    The needs for each category are the actions required to address the identified issues. Where ignorance is an issue members of a category may need information to raise awareness, or practical help. But again, the issues and needs for each category will be different depending on how developed their occupational health and safety culture is.