The preserve of the few: occupational health today

Whatever the window dressing, the main reason the government asked Black to carry out a review is that it is concerned at the cost of sickness-related absence and at the effects that this has on the economy and on its attempts to alleviate poverty in the UK. Black concurs, concluding that “there is a compelling economic and social case to act decisively to improve the health of the working-age population.” She estimates the total cost to the government and the wide economy of working-age ill health at over £100 billion – “an unsustainable burden in a competitive global economy” that is greater than the NHS’s annual budget or the GDP of Portugal. This total includes treatment of health conditions, benefits, lost income tax, informal care and lost production, but excludes the costs of health-related productivity that do not lead to absence, which may be as much as £30 billion a year.

Further impetus arises from increasing evidence of the links between work, health and wealth, and the corollary of unemployment, ill health and poverty. Research that the HSE will publish shortly shows “a clear link between an individual’s health status and the probability of being in work, and also earnings levels for those in work … [as well as] a significant association between the health status of the working-age population and economic growth”². There is, accepts Black, “something of a self-sustaining cycle of good health and good wealth, just as there is a similar cycle of poor health and poor wealth”. The poor-health issues extend beyond the non-worker to his or her family. Similarly, a 2006 review had concluded that work was generally good for physical and mental health and wellbeing, with the “beneficial effects of work … shown to outweigh the risks and to be much greater than the harmful effects of long-term worklessness or prolonged sickness absence”³.

The workplace, says Black, “can be a key setting for improving people’s health and wellbeing”. Initiatives highlighted in responses to her call for evidence include subsidising gym membership, encouraging “active” travel to and from work, subsidising healthy canteen food; the provision of health screening and GP consultations in the workplace. But it was also clear from the evidence that “the reason health and wellbeing initiatives are not more numerous in the workplace today is the lack of a well-developed business case as to why employers should invest in them.”

In an attempt to determine whether there is a business case for employers to invest in health and wellbeing, Black commissioned a report from PricewaterhouseCoopers, which found “considerable evidence” from literature reviews and 50 case studies that health and wellbeing programmes have a positive impact on intermediate and bottom-line benefits⁴. Intermediate benefits included reductions in sickness absence, staff turnover, accidents and injuries and resource allocation, and improvements in employee satisfaction, company profile and productivity. For a programme to work, employers should ensure:

• the programme is designed to meet the needs of the employees; senior management “buy-in” – this is fundamental and must extend to active and visible participation in health and wellbeing programmes;
• the programme aligns with the business’s overall aims and goals;
• they inform and consult employees so that their views drive ongoing change and influence initiatives; and
• they measure the outcome of initiatives.

Black emphasises that the contribution of different industry sectors to occupational ill-health absence varies considerably, and she concludes that “preventive measures need to be tailored to the industry sector, rather than adopting a ‘one size fits all’ approach.” Employers, adds Black, will need “to recognise the value and potential of disabled people and those with chronic health conditions. Too often, employers believe – wrongly – that productivity would be lower and costs higher, whereas the majority will require little or no extra support to perform in the right job.” She reminds employers that many already employ people with health conditions “without realising it”, and that simple physical workplace adjustments “are only part of the solution. There is also a need for a willingness to adjust and refine workplace practices – for example, the provision of phased returns to work and a willingness to offer flexible working patterns.”

One of the most important recommendations that Black makes is for a trial information, advice and consultancy OH service. Such a service should aim to increase the coverage of OH support, particularly among smaller organisations. This could be through signposting employers to existing OH services or directly marketing its own. It should also “link” smaller firms with larger firms that have developed good practice and that might offer seminars, advice and guidance.

Noting the demise of Workplace Health Connect and its reincarnation as Workboost Wales and Safe and Healthy Working in Scotland, Black claims the evidence she received showed that many organisations, especially smaller ones, would use and pay for such a service. The service should be business- and provider-led: best practice, knowledge and expertise, argues Black, are most advanced in the private and voluntary sectors, and “business is more likely to listen to business than take advice from government.” Black says the government should evaluate the success of NHS Plus in England and Wales, which offers a commercial OH service to medium-sized enterprises (as well as to NHS staff), and SALUS and OHSAS in Scotland.

She also suggests that the government review the tax rules governing health, wellbeing and rehabilitation services: employers, for example, incur a tax liability if they pay for rehabilitation of an injury sustained outside of work.

At the workplace itself, Black urges employers to:

• look at job design and management arrangements – employees’ health is likely to be worse where their employment is insecure, the work is monotonous and repetitive, they have little autonomy and discretion over their tasks, there is an imbalance between effort and reward, and they are not confident that they will be treated fairly by employers. Black notes that such issues are covered in the HSE’s guidance on stress. She adds that the public sector could do a lot more, both within the civil service and in terms of the services it provides; and

• support line managers so that they understand that the health and wellbeing of the workers is their responsibility and identify hazards and support those with impaired health, including adapting working practices.

Once workers become ill, employers, says Black, have “significant scope” to facilitate their early return. But up to 40% of organisations do not have a sickness-absence management policy. “Early, regular and sensitive contact with employees during sickness absences can be a key factor in enabling an early return to work,” Black advises, while employers who would like to do something, but claim they fear allegations of harassment, have nothing to fear so long as the contact “takes place in the context of clearly stated policies on sickness-absence management”. Employers, she says, are “often unaware” of the therapeutic benefits of work, whereas they have “much to gain from acceptance that people do not have to be 100% fit to return to work”: indeed, an early return can accelerate, rather than hamper, recovery.

Line managers, adds Black, need training in how to contact absent staff regularly, offer support and suggest back-to-work plans, and approach sensitive topics. Investors in People is developing a health standard to provide a benchmark for employers.

Black also recommends that employers approach GPs to discuss a return-to-work plan. But, until recently, GPs have not seen it as their job to offer advice on work, instead seeing too early a return as an impairment to health, as well as to the doctor–patient relationship. “At the heart of this problem,” says Black, “is a wider lack of understanding about the impact of work on patient health, and the role healthcare professionals can play in helping their patients to stay in or return to work. In spite of a growing evidence base on health and work, these issues have not been incorporated into the training of healthcare professionals.” The upshot, says Black, is that “despite their best intentions, the advice that healthcare professionals give to their patients can be naturally cautious and may not be in the best interests of the patient for the long term.”

Black recognises recent work by healthcare professionals and the health, and work and pensions, departments on awareness raising and training, and the “significant” step represented by the “groundbreaking” Healthcare Professionals’ “Consensus Statement on Health and Work”⁵, which recognises that work can be good for patients and that supporting patients to remain in or return to work should be part of the clinical function. The statement is signed by most of the leading health bodies, including the British Medical Association (BMA) and the General Medical Council. Healthcare professionals, supported by government, says Black, “should take responsibility for helping to translate this pledge into reality”. In addition, those who commission health services should ensure that working-age ill health is tackled at a local level.

The current sick note dates from 1922 and reflects, says Black, “an age when an employer expected an employee to do a specific job rather than today’s more flexible workplace”. The GP must state the health condition and the length of absence that is likely to be required for recovery; there is also a “remarks” section that, theoretically, a GP could use to suggest amended duties to assist rehabilitation, but is all too rarely used in such a way. Black criticises the sick note for focusing on what the employee cannot do and for failing to “readily encourage GPs to explore with patients and employers the options for prompt return to work and the workplace adjustments which would facilitate this”.

Black believes that the ongoing government review of the sick-note system should “take this opportunity to be radical and facilitate a process allowing GPs to create an entirely new ‘fit note’ system, focused on what patients can do”, which would draw on the new Fit for Work teams (see below) to “become a vehicle for providing practical advice to both the patient, and potentially their employer, about how a return to work can be achieved”.

Black also recommends a move towards an electronic sickness-certification system, which would improve information for employers and the healthcare profession in terms of surveillance, variations in clinical approaches, absence patterns and how to deal with them, and allow rapid communication between employers and GPs (with the sick employee’s permission).

The BMA has some concerns about a move to fit notes, even though it has been calling for an overhaul of the sickness scheme for years. Dr Hamish Meldrum, chair of the BMA Council, warns that “GPs are often placed in a difficult position when issuing sick notes to patients in the early stages of their illness and it is not always possible for them to confirm whether a patient is well enough to do their job. This is often determined by the nature of their job and working environment. A major, additional, problem is that GPs can have huge difficulties in accessing physiotherapy and counselling services that would help patients to return to work more quickly.” The detail of the “well note”, he says, will need careful examination, and GPs “must continue to act as the patient’s advocate, not a policing arm” of the government.

There is limited point in many of the improvements advocated by Black unless access to treatment can be expedited; the Royal College of Nursing, for example, describes a nine-month waiting list for physiotherapy and counselling as a “barrier”. Peninsula Medical School undertook a literature review⁶ on early intervention in sickness absence for the purposes of the Black report, and found that early intervention through OH services can play an important role in assessing how and when employees can return to appropriate work. The review highlighted three principles for effective early intervention:

• holistic care in line with a biopsychosocial model – this considers the disease or condition, the impact on mental health and wellbeing, and wider determinants such as work, home or family situation;
• multidisciplinary teams, which are able to deliver services tailored to the need of the individual patient; and
• case managers or support workers, who help the individual navigate the system and facilitate communication between the individual, employer, GP and other clinicians.

Studies have shown that early intervention on the lines of these principles makes for improved clinical outcomes (although these studies originate from outside the UK in places where OH and rehabilitation services are better developed). Further, most research has looked at back pain and there is still a need for evidence to test early intervention, using the three principles, for other conditions, such as mental-health problems.

Black recommends the creation of a pilot Fit for Work service. This would allow early intervention by supporting GPs with new options for referring patients: “It should provide a minimum level of work-related health support to all employees, especially important for those in organisations without any form of OH provision. The service would be based on the three principles above, enabling a “prompt, holistic assessment of patients’ needs”. It would provide patients with an individualised recovery plan, “with a focus on return to appropriate work at the appropriate time as a key part of the plan”. The service would also refer onwards those with more serious underlying conditions at the earliest opportunity. Under the system, instead of issuing multiple sick notes on an inevitable road towards incapacity benefit, a GP would refer a patient through the electronic-note system to the Fit for Work service, which would also liaise with the employer. Black is clear that the options for support would include:

• medical treatment;
• cognitive behavioural therapy and counselling;
• physiotherapy and occupational therapy;
• OH interventions, including an assessment of the appropriateness of returning to work; and
• advice and support for social concerns such as personal finance, housing, family and childcare.

To be effective, Black believes, the Fit for Work service “would have to be based in, or close to, primary care” – trials could encompass location in health centres and GP practices. The trials would also have to enable the determination of the most effective point at which to intervene in the illness.

The problem, Black notes, is that, historically, OH care has been explicitly excluded from the services that the NHS provides: “industrial medicine” was seen as benefiting employers, who should therefore pay for it. But the reality is that many employers are failing to provide OH access, which has a cost to the taxpayer and the economy: in short, OH is “the preserve of the few”.

There is, therefore, argues Black, “a strong case for the NHS being involved in the provision of these work-related health interventions. While there would clearly be significant costs in providing such a service through the NHS, these are likely to be outweighed by significant savings to the taxpayer and the economy overall.” She is not dogmatic, however, and believes that the pilots should also explore private and voluntary sector providers delivering services under NHS arrangements. “If found to be effective, the Fit for Work service should be rolled out nationally.”

“The sheer scale of the numbers of people on incapacity benefits,” argues Black, “represents a historical failure of healthcare and employment support to address the needs of the working-age population in Britain.” Many people have been “written off to a life of incapacity. A passive benefit regime meant that once an entitlement to incapacity benefits had been established, there was little expected of claimants, with no interventions to help those who were interested in work.” As a result of this, 1.5 million people have spent more than five years on incapacity benefit.

Black welcomes the government’s plans to replace incapacity benefit with an Employment and Support Allowance, which will focus on what people can, rather than cannot, do, but says this will not be sufficient in itself to address the problems faced by people made workless through disability or ill health. As such, more needs to be done to raise aspiration and motivation, and address health conditions.

Black believes that people out of work could benefit from the Fit for Work service in the same way as those on sickness absence. So, when appropriate services are established, she recommends that GPs or Jobcentre Plus personal advisers refer incapacity benefit claimants to it. She is not clear, however, how this would link to the existing Pathways to Work and New Deal for Disabled People, beyond saying that where claimants use such provision, referrals could also be made to Fit for Work.

In addition, it is important that the new Work Capability Assessment, which will be introduced for incapacity benefit claimants from 2010, identifies which claimants would benefit from the Fit for Work service, and that the service has the capacity to deal with these referrals, in addition to existing employees. (In his March 2008 budget, Chancellor of the Exchequer Alastair Darling, announced the assessment would be supported by an additional £60 million over three years to help people return to work.)

Black notes too that government is reviewing vocational rehabilitation services and will be providing guidance for employers. She also urges the government to encourage local partnerships, citing good examples such as the Sheffield Health and Work Strategy Group and the health@work project in Liverpool.

The problems around OH include:

• the separation of OH and mainstream healthcare;
• the restriction of OH to those in employment;
• uneven provision of OH and rehabilitation services, with small and medium-sized enterprises poorly served – “indeed, provision is often least concentrated where it is most needed, a striking example of the inverse-care law”;
• inconsistent quality, with an absence of formal standards or accreditation of providers (although there has been some progress in terms of vocational rehabilitation);
• diminishing and ageing workforce;
• a shrinking academic base, such that there is a lack of systematic surveillance and monitoring;
• lack of good-quality data; and
• the historical image of OH – some service users regard it “with suspicion, perceiving it to be part of sickness absence management and even shouldering responsibilities which sit more properly with human resources”.

Tackling this requires bringing OH into the mainstream of healthcare provision, with its practitioners embracing a wider remit and closer working with public health, general practice and vocational rehabilitation. This must be underpinned by five principles:

• OH, including vocational rehabilitation, needs to be fully integrated into the NHS. Black accepts that hers is a long-term goal that requires a radical change within the NHS but that, should the Fit for Work pilots prove successful, would make OH treatment “universally available on the basis of need, not ability to pay”;
• leadership from the professions;
• guaranteed quality of delivery through a nationally recognised system of accreditation, notwithstanding the recent initiatives from the Faculty of Occupational Medicine, NHS Plus and the Vocational Rehabilitation Association to develop service standards;
• a revitalised professional workforce – OH, claims Black, “is a specialty unknown to most trainee health professionals”. To rectify this, health and work should be part of the core curriculum. Broadening and mainstreaming OH would also make the discipline “more attractive” for professionals to enter; and
• a strong academic base, with systematically collected analysed data, and nationally managed research into areas such as the effects of health interventions on employment.

The first point to make about the Black report is to welcome its recognition that OH is but one part of a wider agenda that extends even beyond general health to matters such as a worker’s financial worries. This is also a stark warning to health and safety practitioners that they can no longer pursue workplace safety and health in isolation (although it should be noted that some embarked on a holistic route many years ago). Such an enlightened approach raises the question, however, of how realisable Black’s recommendations are. It is all very well telling safety professionals that they need to address the wider issues, but the reality is that most are hard pressed to cope with the immediate safety and health concerns of the workplace. A biopsychosocial model for health would be tremendous news; the problem is how to deliver it in any meaningful context.

Having laid out the problems and prescription, Black is disappointingly unforthcoming on the detail of the recovery. Instead, she urges the government to establish the framework within which change can be achieved and state how it will take forward her recommendations. To date, the government has said nothing by way of a detailed response. Welcoming the report, the HSE’s chair, Judith Hackitt, noted: “The challenge now lies in not only deciding what should be done in response but who is best placed to deliver on the various elements.”

And, despite commissioning research on the business case for interventions, Black accepts that “there is little evidence on how effective health interventions are in promoting returning to work or how effective work interventions are in promoting positive health outcomes. It is, therefore, almost impossible to conduct any meaningful cost-effectiveness analysis of the health and work agenda.”

A hard-nosed employer might well question, given this absence and impossibility, the justification for Black urging it to invest in wider health initiatives: overall costs of £100 billion mean little to individual employers and are, in any case, much more about the costs to the economy than the employer.

Other reservations abound, including:

• Black recommends that the government ensure that policies across its departments are consistent and complementary and that it acts as an “exemplar”. The “government as exemplar” argument is hardly new – it is part of the HSE’s 2010 strategy, for example – and it remains true that that is more an aspiration than a reality, and many employers believe it is little more than a cynical mantra. Evidence submitted from the Royal Society for the Prevention of Accidents, for example, points out that there are now only seven full-time OH physicians and 25 OH nurses in the HSE’s Employment Medical Advisory Service.
• Is there sufficient capacity in the labour market and potential for economic growth to absorb the increased numbers that would return from sickness under Black’s proposals? Black points to more than half a million unfilled jobs, but so do other government departments equally obsessed with getting the “workless” – parents of school-age children, for example – back into work.
• Black’s emphasis on the need for “good work” to improve health is welcome, but, as the TUC points out, this can only happen if the government “clamps down hard on employers who exploit their staff through bad conditions, long hours or stressful workloads”. Given the government’s Hampton regulatory agenda and the problems currently besetting the HSE and local authorities, this seems highly unlikely to happen.

But whatever these doubts and the fact that many of Black’s recommendations are hardly novel – indeed, some have already started to be implemented during the course of her review – the report is highly significant and welcome. The paucity of OH and rehabilitation provision in the UK is probably the area of health and safety where we lag most behind our European counterparts, and Black’s recommendations here, as in many other areas, make perfect sense. Most crucially, given that the report has come from its own national director for health and work, is supported by so many stakeholders, and fits with its own sickness absence reduction strategy, the government will find it difficult to ignore too many of the recommendations.