Evolution of occupational health 2: recent developments

evolution

OH practitioners past and present look at recent developments in health and wellbeing at work and discuss what role OH nurses will have in future. Noel O’Reilly reports.

As OH services have developed over the past 100 years, the role of OH practitioners was defined by the unique workplace setting in which they worked. As the world entered the 21st century, public policy leaders would begin to envision a broader public health role using the workplace as a setting.

A new era of optimism for OH followed the publication of Dame Carol Black’s review of health and work, “Working for a healthier tomorrow”, in 2008. The key message of this review was that OH services needed to be integrated with primary care as part of a broader public health agenda.

Black’s blueprint for a new model of health and work was based on the principle that work is good for people (Waddell and Burton, 2006). Her review embraced the potential of the workplace as a setting in which to promote public health. She recommended the reform of the sick note, which was seen as an obstacle to return to work after sickness, and the education of GPs about the benefits of work to health. Her report also focused on the health of people who are out of work, which extended the remit of OH beyond the workplace

The three key recommendations of her review were:

  • prevention of illness and promotion of health and wellbeing;
  • early intervention for those who develop a health condition; and
  • an improvement in the health of those out of work – so that everyone with the potential to work has the support that they need to do so.

Timeline: evolution of occupational health

1700 Bernardino Ramazzini, an Italian physician, publishes a book on occupational diseases, De Morbis Artificum Diatriba (Diseases of Workers).

1775, Percivall Pott, a surgeon, finds an association between exposure to soot and a high incidence of scrotal cancer in chimney sweeps, the first occupational link to cancer. He is also the first person to associate a malignancy with an environmental carcinogen (and how wonderful that a Dr “Pott” diagnosed illness among chimney sweeps).

1905 Thomas Legge publishes lectures on industrial anthrax and its prevention.

1935 Association of Industrial Medical Officers (later the Society of Occupational Medicine) is formed.

1948 National Health Service launched. Since that date, it has been a moot point how much the NHS has helped or hindered the development of occupational health.

1951 Dale Report recommends the expansion of existing industrial health services into a national occupational health service.

1952 Royal College of Nursing Occupational Health Section established.

1953 British Occupational Hygiene Society formed.

1968 Tunbridge Report “The Care of the Health of Hospital Staff” published, recommending hospital OH services.

1973 Entry of UK into European Economic Community, initiating the requirement for the UK to implement European directives on health and safety, and discrimination.

1972 Robens Committee on Health and Safety report, which led to Health and Safety at Work Act, is published. Only one of 19 chapters dealt with occupational health.

1973 Health and Safety Executive Employment Medical Advisory Service becomes operational.

1974 Health and Safety at Work Act comes into force.

1978 Faculty of Occupational Medicine is created within the Royal College of Physicians.

1982 Royal College of Nursing publishes the “Education of the Occupational Health Nurse”.

1988 Control of Substances Hazardous to Health Regulations (COSHH) come into force.

1988 The Hanasaari Conceptual Model for Occupational Health Nursing emerges at an OH conference in Finland.

1992 The Association of Occupational Health Nurse Practitioners (UK) (AOHNP) is founded with a goal to increase the representation and profile of OH nurses.

2000 Health and Safety Commission’s Securing Health Together 10-year OH strategy is launched.

2004 Commercial Occupational Health Providers Association (COHPA) launched.

2008 Dame Carol Black’s review of health and work, “Working for a Healthier Tomorrow” is published.

2009 Council for Health and Work is formed with an independent chair.

2009 “NHS Health and Well-being”, the Boorman review, is published

2009 Wolverhampton University stops taking students on its Specialist Community Public Health Nursing ( SCPHN) occupational health courses, amid concern that OH courses were becoming too generalist in order to fit into the Nursing and Midwifery Council’s SCPHN framework.

2010 Fit Note replaces “sick note”, allowing GPs to suggest work that patients may be able to perform before fully recovering from illness.

2010 The Marmot review, Fair Society, Healthy Lives, is published. As one of six policy objectives, it called for “fair employment and good work for all”.

2010 SEQOHS launched, standing for Safe, Effective, Quality Occupational Health Service. A set of standards and a voluntary accreditation scheme for occupational health services in the UK and beyond.

2011 “Health at Work – An independent review of Sickness Absence” by Dame Carol Black and David Frost recommends a national health and work service.

2011 Royal College of Nursing publishes “Roles and responsibilities of occupational health nurses”

2014 Fit for Work Service is launched.

2014 Outsourced healthcare provider Atos quits the contract for the Work Capability Assessment service (providing assessments of work capability for people on incapacity benefits), following a series of critical independent reviews by Professor Malcolm Harrington.

2014 Council for Health and Work publishes “Planning the future: Delivering a vision of good work and health in the UK for the next 5-20 years and the professional resources to deliver it”

2014 Health Education England and the Faculty of Occupational Medicine establish a National School of Occupational Health

2015 A project to develop a Faculty of Occupational Health Nursing is initiated.

Dr Steve Boorman’s report, “NHS health and wellbeing”, followed in 2009. It had always been ironic that the organisation responsible for the nation’s health did not prioritise the health of its own staff, the people providing the services.

Alongside these reports, the Government commissioned a report by consultancy PwC, “Building the case for wellness”, which concluded that “workplace wellness makes commercial success sense” (PwC, 2008).

Public health role in OH

In 2011, the Government launched the Public Health Responsibility Deal, whereby a wide range of employers have undertaken to implement initiatives, such as: promoting physical activity; encouraging smoking cessation; healthy eating; and the use of nationally accredited OH services.

Helen Kirk, head of OH transition at Public Health England, points out that OH has not always focused on work-related illness. “OH nursing began with a sharp focus on workers within the context of their community, whether they worked in factories, mills or mines. If anything, the orientation towards only thinking about issues at work probably arose with the arrival of a national health service,” she says.

“Workers’ health is usually far more influenced by factors outside work than those at work: alcohol consumption; poor diet and obesity; physical inactivity; and sedentary behaviour,” Kirk adds. “Issues like divorce, debt and bereavement cause far more stress than work – we can’t see work in isolation. Even if we split OH from public health, work from non-work, our patients can’t. Work to them is not separate, it is just part of their life.”

Corporate wellbeing models

While the Government has championed a public health approach, much of the impetus for embracing wellbeing at work among larger employers has been the recognition that good health is good for business. Employer’s corporate responsibility body Business in the Community has developed the “Workwell model”. This model has four segments: better work; better relationships; better physical and psychological health; and better specialist support. Only the “better specialist support” segment relates directly to the historical remit of OH nurses, and this does not only relate to nurses but to a wide range of allied practitioners.

To what extent will HR or wellbeing concerns dictate the objectives of OH services in the future? HR directors in larger companies are already viewing OH as a component of an organisational strategy that integrates wellbeing with employee benefits and HR business objectives.

Joanne Anderson, senior consultant at consultancy Towers Watson, says: “In our experience, the most effective OH programme is where OH acts as a ‘hub’ within a sound integrated benefits programme. Each element needs to ‘speak to’ the overarching health strategy of the company, encompassing the whole employee journey from prevention, to being healthy at work, to presenteeism, to short- and long-term illness.”

Anderson adds the caveat that her observations are based on experience working with large multinational employers and heavily weighted towards the financial services sector. She says: “We are seeing a trend with our clients to bring OH into a larger wellbeing context, very much driven by early intervention and directional pathways for treatments (such as musculoskeletal disorders and mental illnesses).

“However, the integration of all aspects of the employee value proposition is a key driver for clients to map out a cohesive employee experience. OH touches many aspects of this journey and, as a result, has multiple stakeholders within a client business. The outcome being that OH services of the future are being shaped by more than just the traditional health and safety aspects of preventing work-related ill health and managing return to work. This will be a long-term play as traditional employer programmes are still very heavily weighted towards employees who are already unwell.”

Black sees no problem in integrating business objectives with OH responsibilities.

“There should be no tension between the objectives of the new occupational health and the HR needs of a business,” she says.

“The business imperatives – service and product quality, productivity, staff recruitment and retention – are best served when the workforce is engaged, and a key factor in securing engagement is recognition that the employer gives the physical and mental health needs of all staff the priority they should command.”

Black points out that this aim is UK public policy on health, and it is an explicit part of recent guidance from the National Institute for Health and Care Excellence (NICE).

“NICE has been a major contributor in making responses to these challenges, with guidance that reaches far beyond the familiar domains of public health and healthcare. The most recent evidence based public health guidance makes recommendations on improving the health and wellbeing of employees.”

The guidance from NICE (2015), has a particular focus on organisational culture and context, aiming to:

  • promote leadership that supports the health and wellbeing of employees;
  • help line managers;
  • explore the positive and negative effect that an organisation’s culture can have on people’s health and wellbeing; and
  • provide a business case and economic modelling for strengthening the role of line managers in ensuring the health and wellbeing of employees.

“These aims add to and refine our ideas of the organised collaborative effort of modern public health,” says Black.

To what extent should practitioners take the lead on wellbeing and health promotion?

What role will OH nurses and doctors play in this collaborative effort? The phrase “that’s management’s job” is commonplace in OH forums, suggesting that once an OH nurse has offered a clinical opinion, their responsibility is at an end. But some nurses are embracing the opportunity to lead broad-based health and wellbeing services, giving them a stake in developing business strategy related to employee wellbeing in the round.

Dr Paul Nicholson, chair of the British Medical Association’s Occupational Medicine Committee, sounds a note of caution. “While the public health/wellbeing agenda can provide an opportunity to market and grow comprehensive occupational health services, there is real risk that the focus of workplace health initiatives will shift to getting people to lead healthy lifestyles taking limited resources away from focusing on occupational risk management programmes,” he says.

“The agenda must be led by the occupational health community rather than by public health professionals if we are to avoid good intentions going bad,” he adds.

OH nurse educator Anne Harrison agrees that there is a balance to be struck. “Occupational health has an opportunity in both helping with prevention and management of chronic conditions, but may have to decide the level at which it incorporates preventative wellbeing strategies into its arsenal,” she says.

Diane Romano-Woodward, president of the Association of Occupational Health Nurse Practitioners, sees a role for OH nurses in health promotion but shares Nicholson’s concerns about the risk of neglecting work-related illness.

“Public health professionals, particularly in local authorities, are waking up to the fact that there are experienced practitioners in workplaces and that workers spend a large amount of their week at work, so there may be an opportunity to positively influence the population’s general health.

“I think OH practitioners may have a battle to focus on their specific area of expertise, the prevention of work-related ill health, rather than being swept up in general health promotion strategies,” she says.

Statistics show a continuing need for resources to address work-related ill health. Health and Safety Executive (HSE) figures show that new cases of self-reported ill health have fallen since 2001/02. However, in 2013/14, the number of new cases increased to 535,000, a similar level to that in 2009/10, from a low of 452,000 in 2011/12. An estimated 1.2 million people who worked in 2013/14 were suffering from an illness they believed was caused or made worse by work.

A large amount of employee ill health in today’s organisations is caused by management practices and culture, and OH nurses have a role in advising employers about this, says Romano-Woodward.

“I recently had a meeting with some HR practitioners about an area of work with a high level of work-related stress,” she says. “My focus was on identifying why this was the case and suggesting targeted training to this group and their managers on management style, for example the HSE line managers competency tool, company culture and general control measures which might be put in place. This might include, for example, adequate meal breaks and rest.

“I would be very happy to spend more of my time doing this, but there has to be a change in organisational perception that “illness” is due to susceptibility in individuals and is strongly influenced by attitudes and conditions at work.”

The 2014 Council for Work and Health (CWH) report “Planning the future” argues that OH can make a contribution to improving employee productivity within the current OH remit. “Of no lesser importance is their [OH practitioners’] contribution to productivity as they advise on optimum human and organisational factors to reduce work stress, ensure fitness for work, and the management competencies required to address worker attendance and sickness absence,” states the report.

However, the launch of a national Fit for Work service in 2014 has added to concerns that OH could be forced into a limited role managing sickness absence. Former OH nurse leader Cynthia Atwell says: “From my point of view, I think that OH was originally there as a ‘treatment service’, when there was a great deal of heavy industry and therefore a number of accidents, which needed to be dealt with.

As a result of the 1974 legislation, in the 1980s there was a step-change to a much more preventive role, when OH nurses in particular fought hard to be recognised as being able to prevent ill health caused by workplace exposures.

“Unfortunately, I feel that OH is now having to react to the Government’s agenda, particularly in relation to the welfare reforms, and therefore OH will be pushed into reacting to sickness absence controls rather than having the time and resources to introduce prevention strategies.”

However, in one respect, the Fit for Work scheme could help to blaze the trail for how OH could be delivered in future by using technology to transcend limited resources. It will use telephone technology to triage people who are absent for work for more than four weeks.

When discussing “occupational health”, it is important to be clear whether or not you are referring to OH nurses and doctors as a profession, or whether or not the term refers to the OH service. Not everybody in OH is a nurse or doctor. For example, in the modern workplace, there are “occupational physiotherapists” who often work alongside OH practitioners.

Other practitioners who work with OH include: human factor specialists and ergonomists; OH technicians; occupational hygienists; occupational psychologists; occupational therapists; mental health support workers; vocational rehabilitation specialists; and health and safety professionals.

The CWH report also suggests that the integrated OH services of the future may need a different name than “occupational health”, noting that: “It is accepted that the term occupational health may not be entirely acceptable nor the most understandable for a marketing strategy that needs to actively promote the considerable and wide ranging benefits of specialist workplace interventions.”

What role will OH nurses have in the future?

OH nurses have been the mainstay of workplace health for decades, but will they have a central role in the future?

Atwell says that nursing skills will always be important. “Basic nursing skills are needed in any healthcare situation – being a good listener, empathy, assessment skills for assessing wellness, good communication skills, diagnostic skills,” she notes.

“There will always be a need for treatment skills. However, the skills may need to be developed in different ways, for example: health needs assessment; health risk assessment; a broader knowledge base of health in relation to work and the effects of work on health; identifying potential causes of ill health and absenteeism with the aim of developing prevention strategies.

“Communication will be vital to this in dealing with reluctant managers who will need to be convinced that looking after employees means better production, attendance and business,” she adds.

Kirk agrees: “Nursing skills in workplaces have been important for a long time and it doesn’t seem likely that will change. What has changed, and will continue to change, is the nature of those skills and the ways nurses support workers and employers.”

Romano-Woodward adds it is through experience in the workplace that OH nurses acquire the work-related competences they share with allied practitioners. “I think nurse training at degree level equips practitioners with an understanding of health and society, and provides the basis for acquiring skills of thinking, logic, writing formally and presenting ideas to others,” she says.

“It could be argued that these skills are common to other health professions, such as paramedics and physiotherapists. In my opinion, real learning about how to practice the art and craft of occupational health begins in the workplace and is strongly influenced by the mentors and skilled practitioners of all professions that one encounters.

“We need to make it easy for highly experienced practitioners of any discipline to be able to formally support students of any discipline,” she concludes.

References

Boorman S (2009). “NHS health and wellbeing – final report”. Central Office of Information.

Council for Work and Health (2014). “Planning the future: Delivering a vision of good work and health in the UK for the next 5-20 years and the professional resources to deliver it”.

Health and Safety Executive, Line Manager Competency Indicator Tool

International Labour Organisation Expert Committee on Occupational Health Second Report (1952). Geneva.

Nursing and Midwifery Council (2005). “Proposed framework for the standard for post-registration nursing”.

NICE (2015). “Workplace policy and management practices to improve the health and wellbeing of employees”. NG13.

PwC (2008). “Building the case for wellness”, commissioned by the Department for Work and Pensions.

Waddell G, Burton K (2006). Is work good for your health and wellbeing? The Stationery Office.

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