There are many work-related illnesses but, paradoxically, the most significant of these is unemployment (worklessness). Both morbidity and mortality are increased in long-term worklessness, most probably caused by increased smoking, alcohol consumption, reduced physical activity and weight gain.2 This has been recognised in a recent government White Paper1 on ways of improving the health of the nation. Only about 50% of people with disabilities are in work, and for those with mental health problems, it is only 21%. Sickness absence is estimated to cost employers at least £11bn per year.3 All state benefit costs amount to around £20bn per year with incapacity benefit amounting to £7.5bn alone, and at least 700,000 moving onto these benefits each year.
This increasing pool of people will suffer increased ill health and add to the cycle of costs to the National Health Service (NHS) and social services. A person signed off sick for six months only has a 50% chance of ever returning to work. At one year this reduces to 25%, and to only 10% after two years. This situation is unsatisfactory both for the individual and the nation, with the costly loss of a useful and productive workforce, and an inevitable additional cost to the NHS. But this situation could possibly be halted or even reversed by using present NHS resources.
Regional task group
Towards the end of 2007, I was asked to contribute to one of Lord Darzi’s many regional groups to think innovatively about the NHS and how it could serve the UK population better.
I think I was the token occupational health (OH) physician (perhaps the only OH physician), and I joined the South Central Clinical Pathways Group ‘staying healthy’ team, which was ably led by local directors and academics in public health. We were a mixed multi-disciplinary group of healthcare workers with the common theme of promoting community and clinical responsibility for preventive health strategies and rehabilitation. At the time I was a substantive NHS consultant physician in OH medicine and my population were the employees of my employing trust, the local university, and also some businesses and district councils.
I have always been concerned about the gap of clinical service that has developed in the provision of OH to the wider working community since the inception of the NHS in 1948. Its specific exclusion at that time was probably for a number of reasons and I will consider these in due course, but my suggestion that it should perhaps be introduced into primary, secondary and tertiary care came almost as a revelation to the South Central Clinical Pathways Group, and they embraced the idea without reservation.
I was then asked to construct a position document laying out the evidence and giving some preliminary costings and resource implications. This was initially titled What the NHS Could Do Better, and has now been superseded in part by the Dame Carol Black review Working for a Healthier Tomorrow.4 This comprehensive and excellent publication has been widely reported, publicised and read. It detailed the economic cost of ill health and its impact on work. It also discussed the significant human cost of dignity and the ability to self-support, and linked this to the health of the nation.
Much of the discussion was connected to primary care provision and disability assessment, with the emphasis on the residual ‘ability’ within disability and pathways of rehabilitation and retraining back to work and self-support, improved health, and greater financial security.
OH speciality
Occupational medicine as a speciality was excluded from the NHS in 1948 because of its partial inclusion within other specialities (respiratory medicine, dermatology, and orthopaedics). Other reasons for OH exclusion from the health service included unco-ordinated or unavailable specialist OH training programmes and an existing and funded facility of OH practice for consultation and advice within many nationalised industries, (the National Coal Board, British Steel Corporation, the shipyards and the Employment Medical Advisory Service of the Health and Safety Executive). This situation no longer exists and specialist training has existed since 1978, with the establishment of the Faculty of Occupational Medicine of the Royal College of Physicians of London.
OH departments were soon present within the NHS and trusts were variably led by consultants or senior nurse managers. The problem here is the limitation of the service to only NHS employees, as most OH departments became part of NHS human resources, and their primary concern was mainly the health of NHS employees, rather than the wider community or population of patients. The service was occasionally widened to include some local industries for the purpose of income generation. There was no association with general medical services or primary care, and the situation has remained much the same for the past 20 years.
The NHS has traditionally undertaken acute and chronic care, rehabilitating the patient back to health with additional occupational and rehabilitative therapy to ensure that the patient can return home and manage complete or partial self-care, perhaps with the help of social services.
The final step of rehabilitation back to work has never been a part of the programme, with the inevitable consequences of an increasing and longer-lived population entering incapacity benefit, many of whom could possibly have been rehabilitated back to full or part-time employment, with a significant benefit to the individual, their family, the NHS, and the nation.
Delivery
For OH delivery, the NHS is presently simply considered as another organisation that requires OH services, and this is of course quite true. It appears to have been forgotten that the total client (patient) base of the NHS also requires OH services, and only the internal market is being properly served.
The majority of small and medium-sized industries do not have an OH service, and many of the larger organisations rely on private providers such as Bupa Wellness, Norwich Union or AXA. The present OH resources within the NHS could provide a much wider and more significant role, but would need expanding and modifying to meet this need.
Many doctors and healthcare workers have indicated this essential need and a broader role, each addressing an important but specific aspect and provision. Professor Mansel Aylward of Cardiff University has considered the process of vocational assessment and vocational rehabilitation as part of the clinical pathway back to work,1 and Dr. Kit Harling of the Department of Health is considering the OH needs of small and medium-sized industries in the NHS Plus programme.
Dame Carol Black in her role of national adviser on health and work is examining the fuller picture with wider involvement of the NHS, Primary Care and the Department for Work and Pensions (DWP). Bringing together and co-ordinating all these approaches may well be the way forward in creating a more comprehensive expert service to facilitate a clear pathway from clinical rehabilitation to full or part-time employment. To achieve this, there are a number of practical steps that may need to be implemented and supported:
1. Resource implication – NHS OH departments would need to grow by at least 50% and probably by 100%, and this would mean in practical terms at least an additional doctor at consultant or specialist registrar level (or a substantive consultant appointment in a presently nurse-led unit), and perhaps two or three additional whole time equivalent OH nurses. This would be sufficient for a trust of 4,000 to 5,000 employees and the population it serves, and would allow the less specialised and more straightforward clinical OH work to be undertaken by the OH nurse advisers.
The more complex multidisciplinary cases, whether they are NHS staff or NHS patients, would probably need to be seen by the doctors, or perhaps a consultant nurse practitioner (although this grade does not presently exist). All referrals would need to be triaged by an experienced occupational health practitioner.
2. Funding – Additional funding for these increased resources will need to be obtained both centrally and locally with arrangements with the primary care trust (PCT) commissioners, the Department of Health (DoH), the DWP and local deaneries. The funding details would need to be considered in due course and would depend on the variety of work undertaken, but the reduction in individuals continuing or entering incapacity benefit would offset the overall cost by many factors of magnitude with an overall contribution to the health of the nation and the national economy.
The practical way in which the funding is organised will be a complex issue, with negotiations occurring between all the interested parties and reimbursement from a central government through the DoH and the DWP. This will be complicated as an enhanced training programme will need to be constructed with appropriate recruitment of doctors and nurses as there are presently insufficient numbers within the speciality to fulfil the proposed service requirement.
3. Training – An enhanced programme of training would need to be offered to both doctors and nurses hoping to specialise in occupational medicine. This would encompass the widening role and would include the Royal Colleges, Faculties and professional bodies (especially the Faculty of Occupational Medicine of the Royal College of Physicians of London and the Nursing and Midwifery Council). Perhaps a greater diet of training in broad speciality areas such as general medicine, psychiatry, orthopaedics and rehabilitation would need to be introduced into the present syllabuses of specialised training, but further detailed consideration of this is not appropriate in this article.
4. Clinical pathways and professional relationships – The pathways of care from acute and chronic illness to rehabilitation back to health and work must be agreed and established between PCTs, the Acute Trusts, and local incapacity benefit offices (through DWP), with referrals being made at primary, secondary and tertiary care levels. Such a pathway will be a new and untested model in the majority of the NHS, and the programme would need to be properly launched to all involved providers and recipients of services with an explanation of its function, limitations, aspirations and funding stream. In Oxford, the very first steps of these ideas may be tested soon, with professional links being made between rehabilitation and enablement services, consultant OH physicians and various officers and administrators of the DWP.
Audit and search
It would be appropriate at the start-up stage to establish a statistics and research programme, possibly at strategic health authority level, to track progress and quantify the benefits in terms of the proportion of patients successfully returning to employment (for more than six months), their respective reduction in benefit payments, and in the longer term, the reduction in the morbidity and mortality of the rehabilitated population. This fits well with the government’s response to Black’s report, and the proposed establishment of a national centre for working-age health and wellbeing.5 Regional audit units (perhaps based at the strategic health authority), should co-ordinate their results with the proposed national centre, and this will lead to detailed analysis of the results, based on the regional strategies.
Eventually, the most cost-effective model will emerge that offers the best return on investment, measured initially by calculating the number of those returning to work in some capacity within the rehabilitation programme, and then progressing to a longitudinal study on morbidity and mortality and the inevitable reduced cost to the national budget. Without this essential collection and analysis of data, the exercise cannot be properly quantified, and this can only happen with a well-constructed and co-ordinated requirement for regional and national statistics.
Conclusion
Why OH medicine has been lying in the healthcare wings and hasn’t been more centre stage is possibly related to its relatively late acceptance as a speciality in its own right, and the difficulties some organisations have had in properly placing and aligning the speciality and the service within their organisation.
This has not helped recruitment, but the training for both doctors and nurses remains vigorous and very comprehensive. The Faculty of Occupational Medicine of the Royal College of Physicians, London, and the Royal College of Nursing and the Nursing and Midwifery Council, have been integral to this process. The diet of study, clinical practice and examination should allow a specialist practitioner to have a thorough understanding of general medicine, epidemiology, statistics, toxicology, environmental health and rehabilitation among many other sub-speciality areas.
Such a set of skills, sensitively and accurately applied, will allow an understanding of the previously under-estimated contribution of OH to the final clinical pathway back to health, self-support, personal dignity and employment.
I find it incredible that it has taken almost 400 years for the speciality to be properly resurrected and recognised for its essential place in practical clinical practice, after Bernardino Ramazzini, the professor of medicine at the University of Padua, stated in 1700 (in his first edition of De Mortis Artificum), that a worker’s occupation may have a remarkable effect on their health, longevity, security and dignity.
In Ramazzini’s time, perhaps gentle folk did not toil for their living, but this is certainly not the case for the majority of the population today. The spectrum of diseases may have changed, but the problems remain, with the added complication of a raft of essential, but complex, legislation.
Counting the cost of unemployment has already been done, but sympathetically and energetically correcting it is another thing entirely, and we have only just started to address this.
Dr Ian Brown OBE, FRCP, FFOM, is director of occupational health, University of Oxford and honorary consultant in occupational health medicine.
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References
1 Fitness for Work, Eds. Palmer, Cox and Brown. Chapter 4, M Aylward and P E Sawney, Box 4.1. 71:680-682
2 Choosing Health; making healthier choices easier. Cm,6374. London. Dept. of Health TSO, 2005
3 Tyler A. The costs for industry. In: What about the workers? Conference proceedings. London: Royal Society of Medicine Press. 2004
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4 Working for a healthier tomorrow. TSO London, 17 March 2008, Crown Copyright
5 Improving health and work: changing lives. The Governments response. Cm7492 November 2008, TSO Crown Copyright.
