At best, only half of UK workers have access to occupational health support. With the Covid-19 pandemic illustrating the need for health and wellbeing expertise, could massively expanding provision be one answer? Nic Paton reports on a recent Society of Occupational Medicine summit that made the case for universal access to OH.
When the NHS was formed back in 1948, then health secretary Nye Bevan complained that the only way he had been able to achieve the Attlee government’s transformational goal of creating a free-at-delivery public health service had been “by stuffing the doctors’ mouths with gold” or, in other words, allowing them to continue to see private patients alongside NHS.
Bevan may not have liked it, but it was a compromise that got the formation of the NHS over the line. However, as Dr Steve Boorman, chair of the Council for Work & Health, perceptively pointed out at a recent SOM (Society of Occupational Medicine) summit, Bevan’s achievement left an increasingly yawning gap.
“I think one of our mistakes goes all the way back to 1948 when we didn’t make occupational health part of mainstream care,” Dr Boorman explained, “I think now is the moment to be starting to be more joined-up in our approach [and] building it into our NHS.”
Bevan’s omission was perhaps understandable in the context of an economy that at the time was heavily based around large factories and manufacturing sites, where employers were able to deliver (and fund) a relatively static works’ nurse or on-site doctor-based model themselves.
The problem is, this model doesn’t work now and, in truth, probably hasn’t for many years. According to the government’s own estimates, barely half of UK workers have access to occupational health provision. Even this is probably over-optimistic, as a recent analysis by occupational physician Dr Paul Nicholson has contended, arguing OH access within the UK may be more like 30% to 34%.
Campaign for universal access
Yet, the past year-and-a-half of Covid pandemic has highlighted the value of occupational health provision, support and intervention as never before. As new SOM president Dr Jayne Moore emphasised: “As a specialty, we’ve come to the forefront in the last 18 months, supporting businesses to return to work and guiding on risk assessments. We have a unique opportunity, and we should capitalise on our raised profile.
Universal access to OH
“Going forward, we in occupational health should be seen as critical to the delivery of healthy workplaces. For instance, being active in the delivery of vaccines and working in partnership with others. We need a multidisciplinary approach within ourselves but also working with other agencies and employers to move the occupational health profile forward,” she added.
This is where SOM’s ongoing campaign to push for expanded access to occupational health comes into play. The rationale is that the government, through its response over the summer to the Health is everyone’s business consultation, is at least talking about occupational health reform, even if that document ducked marking out anything much in the way of transformational change.
With the comprehensive spending review due to take place later this month, and therefore setting departmental spending for the next three years, there is also a logic in trying to make the case for more investment in the profession, although, of course, there will be many competing priorities jostling for chancellor Rishi Sunak’s attention.
The SOM event brought together a stellar line-up of speakers, including Dr Boorman and Dr Moore, Professor Dame Carol Black, former environment secretary Theresa Villiers, Glasgow University’s Professor Ewan Macdonald, Dr Ivan Ivanov of the World Health Organization, project manager at the European Agency for Occupational Safety and Health Dr Ioannis Anyfantis, and Owen Tudor, deputy general secretary of the International Trade Union Confederation.
SOM also published a position paper outlining its take on what ‘universal’ occupational health provision might look in the UK and what it might cost to deliver.
How statutory OH works in Finland
Owe Österbacka, senior expert at the Finnish Institute of Occupational Health, outlined how occupational health provision works in his country, of course a very different picture to the UK.
From initial legislation in the late 1970s through to the 2001 Occupational Health Care Act, the 2002 Occupational Safety and Health Act and then a government “decree on principles of good occupational health” published in 2013, all employers in Finland are obligated to organise OH services for their employees. There is also an emphasis on a multidisciplinary, joined-up service approach.
“Following the legislation is statutory for all employers. As soon as an employer hires his or her first employee, the occupational healthcare has also to be arranged. The self-employed or entrepreneurs, equally, have the right to organise occupational healthcare for themselves,” said Österbacka.
As a result, in a population of 5.5 million people and 2.7 million workers, more than 87% of employers offer basic occupational health, such as prevention of illness and accidents, health and safety, risk assessment and risk management. Some 80% extend this to include optional medical and preventative services, with 91% of working-age wage earners having access to OH provision, meaning OH has “a unique and direct contact with the workplaces,” he added.
“Occupational healthcare is financed by a statutory labour income insurance, and so the set-up is financed by the employers and the employees,” he continued. “Employers can claim reimbursement on the costs of arranging occupational healthcare. The Social Insurance Institution of Finland provides reimbursement for the ‘necessary and reasonable’ cost of the statutory preventative occupational healthcare, but it is also for the option medical care services, up to general practitioner level.”
The average cost of this provision is €452 per person per year (based on 2019 figures) minus an average reimbursement of €189 per person per year, Österbacka said.
UK’s ‘back-street garage’ approach
I’m ashamed that, despite all of the campaigning that has gone on over the years it is only now that we are beginning to see some movement.” – Dr Steve Boorman, Council for Work & Health
Universal access “should be a no-brainer at the end of the day”, agreed Dr Boorman. “I’m ashamed that, despite all of the campaigning that has gone on over the years since people like Dame Carol [Black] painfully put this up the policy agenda [in her 2008 report Working for a healthier tomorrow] it is only now that we are beginning to see some movement.
“I think it is encouraging that, actually, there is movement in terms of more recognition. It has taken a pandemic, unfortunately, to bring occupational health up into the forefront and to make it much more visible in terms of what it can achieve and what it can do. I congratulate all my colleagues who have stepped up and been absolutely magnificent during the pandemic,” he said.
As a serious motor racing fan, Dr Boorman then provided a somewhat damning car-based analogy. “In the UK too often the approach to occupational health is one of treating it as that back-street garage you send your car when it is misfiring but actually already it has broken down. You expect the mechanic to hit it with a hammer and try and get it back on to the road again, even if actually it is a lost cause.
“I think occupational health in the UK deserves to be a Formula One team. It needs to be that multidisciplinary approach that focuses on putting the best person on the track and, actually, the driver is only part of the picture. We need to think much more widely about work design, approaches to work, employer education, all the rest of it so that the agenda is actually very much focused on stopping people coming off the track in the first place rather than trying to fix them once they are broken,” he added.
Senior Conservative MP Villiers praised “the incredibly important work” the profession had done during the pandemic. She highlighted the emphasis on preventative health, mental health and wellbeing and making work a health outcome within the NHS Long Term Plan. “More extensive coverage of occupational health provision has a key part to play in achieving both of those really important goals,” she said.
Facilitating a work environment in which people can take part even if they have disabilities or long-term health conditions is crucial; ensuring our work environments are healthy is crucial.” – MP Theresa Villiers
“I would also highlight and acknowledge that a very important element of the government’s approach to social justice and tackling poverty is that as many people as possible should be in work. And, of course, we are all being asked to work longer with increases in the pension age. So, facilitating a work environment in which people can take part even if they have disabilities or long-term health conditions is crucial; ensuring our work environments are healthy is crucial.
“I welcome the activity the government has engaged on on this; including the recent government consultation, and I would very much agree that an element of the additional funding which is being channelled into the NHS to support its catch-up and also its long-term plan for the future does need to focus on workplace health initiatives,” Villiers added, pledging that she would be pressing ministers “to take further active steps to improve access to occupational health services.”
Supporting gig economy workers
Intriguingly, and positively, Villiers also recognised and highlighted the need for occupational health and wellbeing support to be extended, somehow, to more precarious occupations and the gig economy.
As she put it: “The need for better occupational health is obviously particularly acute in the so-called gig economy. So, in looking to improve the security of approving a shift to more secure contracts and better rights for workers, I hope that occupational health will play an important part in what the government is seeking to achieve.”
The event concluded with a presentation by Professor Maggie Rae, president of the Faculty of Public Health and reflections, Dr Steve Nimmo, president of the Faculty of Occupational Medicine (FOM) and SOM’s Moore, who took over from Professor Anne Harriss as SOM president in June.
“If you want to get to the adult population [in terms of health], one of the best places is through the workplace,” argued Professor Rae, though warning that Britain was in danger of “becoming the most unhealthy population in Europe.”
Critical role in managing long Covid
I’d say this is a crisis now. It’s very, very short-sighted not to have proper access. It is unacceptable that 50% of UK workers do not have access to occupational health services.” – Professor Maggie Rae, Faculty of Public Health
Office for National Statistics’ figures on the extent of long Covid – with its suggestion in September that nearly a million people were experiencing self-reported lingering symptoms from the virus – were “incredibly shocking”, Professor Rae said, “again, we have to shout out for occupational health to be part of the solution for that.”
She added: “What a difference [occupational health] could make. I know many people, colleagues, who have had reported on excellent interventions from occupational health. So, let’s get those case studies out and let’s celebrate what can be done to help people.
“The changing work environment also poses challenges for workplace health. And I think that occupational health expertise is critical in supporting return to work, risk assessment, vaccine delivery and everything else that needs to be done.
“We continue to demand access to occupational health; I’d say this is a crisis now. It’s very, very short-sighted not to have proper access. It is unacceptable that 50% of UK workers do not have access to occupational health services. And the lack of access to the existing health inequalities we have already – and they were existing before Covid and they are going to get a lot worse – what a difference we could make if we could increase that access rate and really get it to some of the areas of the workplace where it is not available,” said Professor Rae.
Challenge of expanding the OH workforce
Of course, one on the ongoing challenges underlying all this is how, practically, to scale up what has been up to now a relatively small specialty and profession, as FOM’s Dr Nimmo highlighted.
“I think what is going to be absolutely key to this is workforce planning. Obviously, we need the investment to take things forward but if we don’t have the workforce there, then we’ll just simply not be able to deliver this,” he warned.
“I would certainly envision universal access being based around accredited specialists in occupational medicine, maybe in a kind of ‘hub and spoke’ model, with various non-specialist doctors and other allied health professionals delivering some of the services at the workplace and the accredited specialists having a slightly more strategic role.
“The Covid pandemic has done us, in many ways, a huge favour, partly by raising our profile and showing how important we are, certainly in terms of risk assessment and risk stratification. But, also, in highlighting that there really are nowhere near enough of us,” Dr Nimmo added.