Workplace Health Connections

The massively powerful but apparently cash-strapped nurses union the Royal College of Nursing seems to be out of step with one of the biggest changes to health policy in a generation. A week before Dame Carol Black is set to announce a raft of recommendations aimed at boosting access to occupational health services, the RCN is under fire for getting rid of one of their professional advisers for occupational health nurses.

Finally Dame Carol Black’s report on the health of the working age is out, Working for a healthier tomorrow.

The rhetoric is great, especially if you are an occupational health practitioner, but what will it mean in practice? This begs a lot of questions. Leaving aside the stuff that’s been trailed already (sick notes, sorry ‘well notes’, consensus statements) the big ideas are:

Four days after Carol Black's epoch-making, earth-shatteringly important report on the health of the working age it is difficult to tell how profound are the shock waves rocking UK PLC. So I have done an in-depth survey (i.e. I’ve looked around the office). Well, no change here. The chocolates are still piled on top of the filing cabinet. We’re all still slouched in front of our PCs in postures straight out of an ergonomist’s training manual. The national news media had moved on by lunchtime on Monday (the day of the report’s launch).

Occupational Health journal, which from the April edition incorporates Occupational Health Review, has the task of looking at last week’s report on the health of working age people from Dame Carol Black and analysing how likely it is to succeed and what is likely to happen as a result of it. What do you think? Here is my initial stab at unpacking the key themes (in no particular order) :

Today is the Society of Occupational Medicine's annual conference and president Dr Gordon Parker has stated that occupational health services  should be free at the point of delivery in the NHS. The call comes in the week the NHS celebrates its 60^th birthday and the day after Lord Darzi announced his proposals for the future of the NHS. I would like to support the SOM's aims but  they do raise a few complicated questions.

There is the question of who is going to provide these OH services. The SOM seems to be fixated on OH doctors and nurses doing it but in reality there are never going to be enough available and a lot of the services are not of a primarily clinical nature in any case, for example "benefits advisers and others associated with workplace wellbeing" to quote the SOM.  There are also case managers, disability assessors and a range of other services which are unlikely to be provided by doctors or nurses. 

 Will NHS Trusts be willing to use NHS funding to provide services which are not 'clinical'? It all boils down to the cost benefit case. In an apparently under-funded service where rationing is the norm, could we, to give one example, demonstrate that return to work through psychological therapies would save a fortune on anti-depression prescription drugs? If we save millions on incapacity benefit can that then be reinvested in improving NHS services? Over to you, Lord Darzi.  

For the time being it is safe to assume that employers will be footing the bill for OH for some time to come.

A report out this week finds the government is under  fire again for failing to address the tax barriers to employers investing in health promotion and return to work interventions. Now that Dame Carol Black's recommendations demand early intervention to get people off sick and back to work and keep them there there, the government has run out of excuses not to change a system that is unfair and riddled with contradictions.

For example, if employees are exempt from tax when their employers provide an Employee Assistance Programme (EAP) (which allows staff to discuss health issues not related to their work), then why should an employee be taxed when their employer pays for them to join a private gym? Currently there is tax relief when a big employer provides a gym or sports facilities but employees in smaller firms are penalised if their employer pays for private gym membership. This is a barrier to smaller employers investing in the health of their staff. How can this tax regime be justified when the Black review points out that the vast majority of employees without access to occupational health are working for small and medium sized companies.

Then there is the issue of tax on employers who spend to get sick staff back to work. Even if the government baulks at introducing tax incentives for employer spending that promotes health among people who are not incapacitated, surely it should provide tax exemptions for all spending on vocational rehabilitation, regardless of whether the illness or injuries are solely work-related or not. Currently if an employer pays for an employee's treatment to get them back to work for reasons which are not solely work-related the employee has to pay tax on it. Yet there are often long waiting lists on the NHS meaning treatment is provided too late to stop the employee swelling the ranks of those on incapacity benefits. Taxing the employee completely contradicts the aims of Dame Carol Black's recommendations. 

Realistically, employers may prove reluctant to help fund  a national OH service  without any financial support.The government should consider reinvesting some of the money it plans to save by cutting the numbers on incapacity benefits to support employers who are expected to foot the bill for getting sick employees back to work. This may have to be done through private medical insurance (PMI). However, up until now the government has had a very Old Labour suspicion of PMI despite its aim introduce more private sector investment into the NHS. The solution is to introduce tax exemptions on PMI and the use of private medical services only when they are used for the purposes of vocational rehabilitation. Surely that would be a more joined up way to achieve the government's objectives for the health of working age people. 

The government is due to respond to the Black review in the autumn and if it fails to address the non-sensical tax system it will be failing employers, employees and itself.