Dame Carol Black’s report on the health of the working age population in the UK, Working for a Healthier Tomorrow, calls for a redefinition of the occupational health discipline and for a greater collaboration between medical and non-medical practitioners, including within the NHS.
In an interview with Occupational Health, Carol Black said her report, and the national debate that it has generated, should provide an opportunity both to restructure the discipline, and determine where its future lies, and to address societal health issues that were first raised by Sir Douglas Black in his radical assessment of inequalities in health in the UK population in the 1980s.
Carol Black’s report1, which takes account of more than 260 written responses to her call for evidence, is far more cautious than the controversial, earlier Douglas Black report.
It contains no prescriptive answers but clearly identifies weaknesses in the current arrangements in the UK. In particular, the separation of the occupational health system from the NHS and the lack of the cross-professional collaboration needed to tackle common health problems are identified as significant problems. Carol Black hopes her report will be instrumental in development of “more visible, invigorated and multi-professional occupational health activity”.
In tackling the challenge of common health complaints that are the main contemporary cause of sickness absence and worklessness, Carol Black says that not only is the NHS not currently set up to respond appropriately but neither are GPs, public health specialists and occupational health specialists operating in a sufficiently collaborative way to address the problems.
Carol Black does not deny that the primary function of the NHS is to treat people with serious disease or illness. But one of the questions she raises is, “Why does occupational health remain outside the national system, and should it remain so?”
She finds it unacceptable that the national health system “has no way of dealing effectively and efficiently with the conditions that take people out of work or keep them persistently out of work”.
Although sickness absence is rarely caused by killer diseases, like heart disease or cancer, Carol Black says, “One has to ask why these problems aren’t dealt with efficiently at an earlier stage.”
A year ago Carol Black had floated the idea of appointing “directors of occupational health” within the NHS to address these issues. But she now cautions against such ‘top-down’ solutions. We must be careful not to over-medicalise the problems, she says: “Good vocational rehabilitation usually requires non-medically qualified occupational health specialists, such as case managers.”
Carol Black is not recommending the establishment of any new body (such as the Institute of Health and Work proposed by NHS Plus in its submission). But she does not preclude the existing NHS Plus services playing a greater role.
“We do support NHS Plus but that is one of a number of ways of expanding such services and addressing these problems,” she says.
And the need for continued stress on the familiarisation of GPs with occupational health principles is strongly affirmed. “Since public health issues and lifestyle diseases are closely related to one’s ability to be in work, it is essential that GPs remain part of the equation,” Carol Black says.
Services for all workers
The review sets out a new approach to supporting the health of working age people, but accepts that this will require the co-ordination and integration of a range of professional disciplines, effectively creating a new umbrella speciality. “At the heart of this speciality will need to be a more extensive, holistic approach to occupational health,” Carol Black says.
OH professionals must be prepared to adapt “radically and rapidly”, to develop new standards of service delivery and to ensure the supply of properly trained professionals to play a leading role in these new multidisciplinary rehabilitation teams. There will need to be formal accreditation of all providers involved in supporting working age people, and OH professionals will need to work with other professionals, and to widen their scope beyond helping those in work, so as also to include those not in work, the report urges.
Because occupational health services are currently disproportionately concentrated in a few large employing organisations, Carol Black’s report proposes new pilot projects to provide evidence of the need for effective new types of support for smaller companies, notwithstanding the failure of the Health and Safety Executive’s efforts in this area.
A new Fitness for Work pilot scheme to provide OH support, under the NHS banner, is proposed this would be delivered by a range of providers and extend access to occupational health to more employees in small and medium-sized enterprises and even to the self-employed.
The Fitness to Work scheme would be an “early intervention vocational rehabilitation service” to help tackle long-term absence from work. If the proposal is accepted by the government, the scheme would run on a trial basis, providing case-managed, multidisciplinary services encompassing treatment, advice and guidance for people on long-term sickness absence and “could generate significant savings for the economy”, the report suggests. Services envisaged include:
Exercise and physical training and activity
Cognitive behavioural therapy and counselling
Educational elements, for example on back care
Occupational health interventions, including assessment of appropriateness of returning to work, for example, workplace risk factor assessment and modification
Debt advice and counselling
Relationship advice and counselling
Continuation of self-care and self management.
The role of GPs
Carol Black’s report believes that, if such services were widely available on the NHS, occupational health services could be available to all people of working age. Such an early intervention service would tackle the market failure that has resulted in limited access to high quality occupational health services that employees of smaller organisations typically experience. Individuals, employers and healthcare professionals must be encouraged to widen their traditional responsibilities and the public sector must set an example through its own policies and practices.
The review suggests that GPs should be able to refer working age people to services that not only focus on medical interventions, but also deal with the necessary non-medical interventions to enable a return to work, for example, liaising with employers over reasonable adjustments to jobs.
Carol Black accepts that this form of referral does not easily fit in the current NHS service framework but her recommendation is that consideration needs to be given to developing a new, broader speciality that takes on such responsibilities.
The business case
While US employers have been encouraged to invest in employee health promotion and wellbeing schemes for some time, there is little good quality evidence relevant to the UK on the cost and benefits of such interventions, Carol Black says. That is one of the reasons that only pilot schemes and trials are being proposed in her report. However, one of three principal reports commissioned by Carol Black for her review (to be published as a supplement to the main report) is an analysis of the health and wellbeing interventions undertaken by 55 UK employers that provides strong evidence of the business case for investing in such interventions.
This report2, prepared by PricewaterhouseCoopers, comprises a series of anonymised case studies and the development of a model for evaluating health interventions and their impact on organisational performance for example, how data on sick leave, absence, and staff morale can be used to demonstrate the value of health promotion activities.
PWC concludes that, although there “is no clear business case that demonstrates wellness programmes have a direct financial return” to a business, “demographic, societal and economic realities” increasingly under-pin wellness programmes in leading UK companies.
“Our difficulty,” Carol Black says, is that because companies haven’t collected their data in the same way – and have not measured productivity in the same way, for example – comparing company performance has not been easy.”
The PWC report does not identify companies by name but Black notes with enthusiasm the innovative wellbeing programmes run by the most progressive companies, such as the pharmaceutical company GSK.
The Carol Black review also includes preparation of the first-ever baseline data on the health of Britain’s working age population. This concludes that although we are living longer, this is not reflected in a similar improvement in the health of the working age population as a whole. Monitoring this baseline will be critical, the report suggests, as will commissioning an extensive programme of further research to inform future action with an evidence base.
Other specific recommendations in the review are that:
- the government, in collaboration with employers and representative bodies, should develop a voluntary code of practice for employers to sign up to, building on the HSE stress management standards
- the government should encourage and support high-profile campaigns to tackle workplace stigma about ill-health and disabilities, particularly mental ill-health, and encourage employers to be more willing to employ staff with health conditions
- appropriate priority should be given within the NHS to services for working age people and commissioning organisations should consider how best to establish local champions for health and work
- the government should explore practical ways to incentivise smaller employers and organisations to overcome prohibitive start-up costs to health and wellbeing initiatives
- the government should consider how the tax, insurance and statutory sick pay regimes can be used to offer incentives to the support of those with disabilities or health conditions.
Work in the prognosis
On many issues, Carol Black admits, her report raises questions about the future development of occupational health, rather than providing answers. “I would not be so arrogant as to make prescriptive recommendations,” Carol Black says. “The [limited] evidence base is only sufficient to justify the pilot schemes that we’re proposing. It is up to the leaders within the profession to pick up the baton.”
That process began last month when a ‘groundbreaking’ consensus statement was signed by the BMA and 30 other medical professional colleges and bodies. The signatories commit themselves to the promotion of the link between good work and good health and to the principle that supporting patients to stay in work should be part of every healthcare professional’s clinical management responsibility.
The government is expected to respond to Carol Black’s recommendations in the summer.
- Supporting the health of working age people requires the co-ordination and integration of a range of professional disciplines
- A new Fitness for Work pilot scheme drawing on the biopsychosocial model, to provide OH support under the NHS banner, is proposed by the Black report
- Services would range from physiotherapy to counselling on matters such as debt and personal relationships
- There has, to date, been no clear business case for wellness programmes in the UK
- Demographic, societal and economic factors increasingly underpin wellness programmes in many leading UK employers.