improving the law by introducing agreed new and revised health‐related legislation and/or guidance and by removing unnecessary legislation; increasing the involvement of health and safety representatives; increasing fines/sentences and other disincentives to breaches of the law; increasing information on the economic benefits of addressing occupational health in order to help promote compliance; raising awareness of the law within priority groups (e.g. small firms); securing consistent enforcement action on health issues; increasing the involvement of interested parties (e.g. trade associations) to produce standards; 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.
Programme 5 (to ensure that appropriate mechanisms are in place to deliver information, advice and other support on occupational health) was particularly relevant to occupational health professionals. The aim was to give everyone access to appropriate occupational health support. It planned to examine ‘the feasibility of new legislation on the accessibility and availability of occupational health support’ and ‘ensure that support is provided by professionally skilled people when appropriate’. One recommendation was to provide occupational health training for primary care teams.
In 2000, the Report of the Occupational Health Advisory Committee and Recommendations on improving access to occupational health support was published (OHAC Report). It made the point that changing patterns of employment mean that an increasing proportion of the working population are employed in small enterprises where there is no ready access to occupational health advice. The report drew comparisons with the position in other Member States of the European Union: from France where occupational health was very much grounded in occupational medicine, to Finland where all employers must have a multi‐disciplinary service, 50 per cent of the costs of which could be reimbursed through national sickness insurance.
The Committee reported that in the UK public sector almost half the total workforce had access to some form of occupational health advice, but that the picture was very different in the private sector. There was a decrease in the number of people covered by in‐house services. Indications were that smaller companies either did not use occupational health support at all or relied on GPs or nurses, some of whom were not trained in occupational health. EMAS, the HSE and local authority inspectors were a source of information and guidance, but their resources were stretched. Employers of small‐ and medium‐sized enterprises (SMEs) had little awareness of occupational health legislation.
Even where occupational health support was provided by employers, it was often viewed with suspicion by workers who saw it as being concerned mainly with sickness absence monitoring. ‘The fundamental issue is one of recognition that the prevention of work‐related ill health should form an essential aspect of the running of any organisation.’ Attention needed to be paid to tackle health inequalities throughout the workplace. Women, ethnic minorities and the disabled might need different treatment from other workers. There was a need for partnerships at local level. Occupational health support should be linked strategically with NHS and local authority initiatives. One example of such a partnership was the Sheffield Occupational Health Advisory Service which was developing a service to patients through the four Sheffield Primary Care Trust practices. It had created a Manual of Occupational Health in Primary Care. A similar organisation was Health Works in the London East End Borough of Newham.
There was debate about whether a change in employer behaviour could be brought about without new legislation to make the provision of occupational health support mandatory. Enforcement, however, would be challenging and the patchy availability of occupational health support would create difficulties in some areas.
The TUC supported the creation of a duty on employers to ensure that employees had access to individual medical advice. An alternative would be legislation to require mandatory self‐assessment and auditing by employers, with tax incentives for employers who performed well (a pilot scheme existed in Alberta, Canada).
One of the most effective incentives for individual organisations would be convincing evidence that the costs of ill health interventions would be outweighed by the benefits.
A project in South West Water concluded that the cost to the industry of work‐related ill health amounted to £8,650 for each worker affected. It might be that the imposition of a charge for the costs of the treatment of work‐related ill health through the NHS on employers’ insurance companies, leading to higher premiums, would make employers more careful. This would, however, be more effective for accidents than for diseases because the latter often take longer to develop and are difficult to attribute to a particular employer.
As regards the delivery of occupational health support there should be a three‐tiered approach. The first tier should involve the GP, safety representatives, trade unions, trade associations and so on. The second tier would be professional advice from, for example, a safety adviser, occupational health nurse with a basic qualification, or occupational hygienist. The top tier would be professional advice from a specialist, for example an experienced occupational physician (and, I suggest, an experienced OH nurse practitioner).
There should be more training for GPs in occupational health, certainly where they were contracted to provide OH services to employers without possessing even the basic qualification of the Diploma in Occupational Medicine. Primary care trusts should have available specialist expertise in occupational health and safety. Some larger practices might have a doctor or nurse recognised as an OH specialist. There were insufficient numbers of trained staff to support a national occupational health service provided through the NHS.
Worker support and involvement was central.
Employers need to secure the practical and enthusiastic commitment of their workforce to make sure that preventive approaches are actually implemented.
It was important that workers were not only consulted, but also given the opportunity to contribute proactively, especially in the process of risk identification.
In conclusion, there was not one solution by itself that would meet the occupational health support needs of everyone; flexibility was the key to delivery mechanisms.
Following the OHAC Report, a number of research reports were commissioned by the HSE, including The evaluation of occupational health advice in primary care (2004) and Review of occupational health and safety of Britain’s ethnic minorities (2004).
Good work is good for you
In 2006 a further strategy document was published by the government: Health, work and well‐being – caring for our future. In the new century the emphasis had shifted from the importance of protecting the health of workers to the need to reduce the numbers of claimants on incapacity benefit. Rehabilitation was the new mantra. Central to this philosophy were the results of the report of Gordon Waddell and Kim Burton: Is work good for your health and well‐being? (2006). Their answer was strongly in the affirmative. Their research demonstrated that those in work are on the whole healthier than the unemployed and that the longer a worker is absent sick from the workplace the less likely they are ever to return to work. It is not merely a financial issue: social interaction and a feeling of self‐worth are also important. The strategy combined both occupational and public health for working people. Dame Carol Black was appointed national director for work and health in 2006 and in 2008 produced her seminal review of the health of Britain’s working age population: Working for a healthier tomorrow (Black Report). Based on a specially commissioned report by PricewaterhouseCooper, the review stated that investment by employers in well‐being was rewarded by lower rates of sickness absence, staff turnover, accidents and injuries, alongside improvements in employee satisfaction, company profile, and productivity.
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