Three presentations at the Health and Wellbeing at Work conference in March posed intriguing questions about occupational health’s current and future role, including arguing the case for a national, mandatory service. Nic Paton listened in.
It is a year now since the then minister for disabled people, health and work, Sarah Newton, said the government was “certainly not ruling out” the idea of making it compulsory for employers to provide and invest in occupational health for their employees as part of its review of workplace health.
Newton become a ministerial casualty of the government’s ongoing Brexit woes in March, but her suggestion continues to resonate with the profession. So much so in fact that it served as something of a backdrop for three complementary presentations on the future of occupational health and occupational medicine at the Health and Wellbeing at Work conference in March.
First, Dr Anne Raynal, an independent specialist occupational physician and a member of the British Medical Association’s occupational medicine committee, posed the question “should the provision of occupational health services be a national requirement?”. Then Nick Pahl, chief executive of the Society of Occupational Medicine, discussed how occupational health could enhance its brand within the workplace, something that, arguably, needs to be a pre-requisite for any “national” OH service hoping to gain traction with perhaps sceptical employers. Finally, Dr Anne de Bono, president of the Faculty of Occupational Medicine (FOM), discussed the current, and potentially future, place of occupational medicine within this changing health and work landscape.
While all three presentations were discrete, they nevertheless provided intriguing food for thought around some of the current and future-facing issues facing the profession, not least around the specialty’s brand, reputation and profile; its ongoing capacity, recruitment and retention issues; and the opportunities but also the challenges that scaling up to some form of national, mandatory service could pose.
Dr Raynal argued she “begged to differ” with the reflections of Dame Carol Black the day before at the conference (and highlighted in June’s edition), where she had suggested that “enormous progress” had been made in terms of health and wellbeing in the decade since the publication of her landmark review Working for a Healthier Tomorrow.
“I think our workforce in this country is still exposed to a substantial number of hazards in the workplace, particularly those working in small and medium-sized enterprises, which employ more than half the workforce in this country. They have very poor access to occupational health services,” Dr Raynal said.
Yet it wasn’t always like this. The UK, being one of the first countries to industrialise, was also one of the first to introduce health and safety legislation, in 1802. By the mid-1800s, early forms of health surveillance had even begun to be introduced, she pointed out. Indeed (and ironically, given Brexit) it is British health and safety and health surveillance rules that have formed the core of much of European Union regulation and legislation in this area.
Across the EU, average compliance rates for employers providing health surveillance for at-risk workers were 65%, rising to 93% in France, Dr Raynal pointed out, compared to just 18% in the UK. “My interpretation of this is that we are already cheating. And where is it going to go from here?” she said.
Occupational health surveillance in France, Dr Raynal added, was a legal requirement, whereas in the UK it was risk-based. “The employer has a duty to assess the risk and if they feel or are persuaded there is a risk to offer health surveillance. But we know that that rarely happens,” she said.
There was, she added, a statutory obligation on UK employers to provide medical surveillance, but only for the most risky hazards, such as asbestos, lead and ionising radiation, compressed air and certain chemicals under COSHH. “But that is 0.1% of our population compared to our European neighbours, where there is an obligation to provide health surveillance for all at risk.
“It is reflected in the number of cases that are reported. In the UK, for 2014/15 (but it hasn’t changed much) just over 1,500 cases of occupational disease were reported to HSE. In France it was more than 51,000, and France has a smaller workforce. So you can see this reflects that occupational health surveillance is not being undertaken in this country to any appreciable extent,” Dr Raynal said.
How and why did this situation come about? First was the decision in 1948, when the NHS was established, not to include occupational health services. “Industries were expected to make their own provision, as more than half the workforce was employed by publicly owned industries, which self-financed services. It was deemed unnecessary to impose an additional burden on the public purse after the Second World War to provide this service,” explained Dr Raynal.
“However, we know that the employment structure has changed radically in this country in that we do not have nationalised industries anymore. We know more than half the workforce is employed in small and medium enterprises, where they have extremely low access to occupational health services; in fact there is an inverse care law in that the more hazardous and risky the jobs are in general, the less access there is to an occupational health service.
“It is a cost for employers, employing doctors and nurses with specialist qualifications and other ancillary occupational hygienists, psychologists, ergonomists and so on; it is expensive, there is no doubt. The alternative is occupational health technicians who, if they are integrated into a team, are extremely valuable colleagues. But there is no requirement for occupational health technicians to work within a team and there is no regulatory body to whom they report or who checks their standards,” Dr Raynal continued.
“It is said the NHS is our national religion; the principle of access to healthcare on the basis of need should come first. However, we do not apply that to occupational diseases. Those most in need have least access. I believe, and the BMA occupational medicine committee feels this is a very important issue, that we need to campaign to government about this, about making access to appropriate, well-resourced occupational health services a priority for all working people in this country,” Dr Raynal added.
But does occupational health, in effect, shoot itself in the foot in the context of these “big picture” arguments by failing to promote and articulate its value effectively enough? Certainly, as reported in the June edition, two recent reports from the government’s Work and Health Unit (WHU) have suggested that many employers remain woefully ignorant about what occupational health can do and its value compared to its cost. Moreover, because OH is such a small specialty and therefore always in such demand, there is often little if any incentive for providers to engage in marketing, promotion or employer or employee education.
As Nick Pahl highlighted (although it must be stressed this was before either WHU report had been published) does occupational health pass what we might term “the dinner party test”? He said: “Would you buy what we sell? If you were a customer, would you buy that? We socialise, we go to dinner parties or whatever, and some people might say ‘what is occupational health?’. There is often confusion between it and occupational therapy; there is not a lot of clarity about what occupational health is.”
In essence, does OH have a bit of a PR/image problem, both in what it does and delivers and even in its name? As Pahl put it: “I think there is something a little bit old-fashioned about the words ‘occupational health’, but maybe we can use that in a positive way. Sometimes words that have a legacy about them can be quite powerful.
“I don’t think we should throw out the word ‘occupational’ but there are ways we can move our brand forward by using key words such as ‘health at work’, ‘wellbeing’, ‘wellness’ and so on. But I do think occupational health still has real resonance both in the UK and globally, and still has that leadership role.
“One of the things I perceive is there is often a slight frustration in that contracts or activity is reactive, after the event, rather than preventative. The better the contract, the better the understanding and we can move to that leadership, preventative, role.
“Are we in touch? I think we are, but we need to make sure we are keeping in touch. For example, is occupational health seen as a punitive service? With occupational health there can be a certain aspect to it that is punitive; it can be used by managers to fire someone, and that’s not easy to project a positive brand in those situations.
“So, what are we for? And what do we do that nobody else does? And what is the importance of what we do? What is the single most important thing that makes a difference to our customers?” he added.
Pahl highlighted SOM’s recent work – and 2017 report – around articulating “the value proposition” of occupational health, the financial, legal and (although most hard to quantify) moral benefits of investing in health and wellbeing. “We need to build our brand promise through the quality of what we deliver. What are the results of the business case or return on investment? What is underneath that perhaps rather fluffy concept of ‘brand proposition’? And we need to build our occupational health offer, and that can mean bringing in things like wellbeing, where there is a clear interest,” he said.
Capacity and leadership
Finally, FOM president Dr Anne de Bono took conference delegates on a lively canter through “the place of occupational medicine in the health and work landscape”.
She also referred back to Dame Carol’s Working for a Healthier Tomorrow but, unlike Dr Raynal, she argued that, to her mind at least, there had been progress, not least in terms of the recognition that work, especially “good” work, is good for health and wellbeing. “There is an increased interest from the government in work and health; no signs of funding, but increased interest. And there is a definite focus on improving employment chances for those with long-term conditions and disabilities, and that was summarised in the government white paper Improving Lives.
“But there is a big, big elephant in the room. And I am going to be quite controversial. The big elephant in the room in occupational health is ‘who does what?’. Where do they do it, when do they do and, I am just going to say this, what is the place of occupational medicine and what is the place of the occupational physician? I think it is really important for us as a faculty; it is important for us as a much wider specialty of occupational health to decide where we sit and what we should be doing,” she added.
As Dr de Bono highlighted, this question goes to the heart of the capacity, recruitment and retention problems that continue to hamstring the specialty – both occupational health and occupational medicine – in terms of meeting demand and maximising potential.
“How can people agree more funding for trainees in occupational medicine when we don’t know what they’re going to do? And I think we just have to take note of that,” she said.
In 2012, there were 708 occupational physicians on the specialist register, she said. Now it is 571. “That is almost a 20% decline. Public health has similarly declined. Medicine, including acute medicine, has increased. Surgery has increased, and psychiatry has had a very small fall. But that is worrying. And we’re getting older,” she said.
“The other thing that people need to know is that occupational physicians are amongst the most likely doctors to be complained about. One in five occupational physicians will be complained about to the GMC; that is very high and much higher than most other specialties. The good news is that the complaints are very unlikely to be upheld or followed by warnings or sanctions. But I think that is also a matter of concern.
“So if you thought that we were going to conquer the universe, these figures perhaps bugger our plan. I would love a situation where everybody has access to the services of an occupational physician in the same way as, if you need it, you have access to the services of a surgeon or obstetrician or a geriatrician or whatever else it may be. But I don’t think on the present figures that we can actually conquer the universe.
“If we look at how small we are in relation to the number of GMC-registered doctors, we have 571 accredited specialists, probably about another 1,000-2,000 occupational health physicians, or doctors with an interest in occupational medicine who have done the diploma in occupational medicine and are practising as part of that portfolio. And there are about 73 trainees in occupational medicine. There are only 60 consultants in the NHS now; there were 80 two years ago and 200 in 2000,” she added.
What, then, did the future hold? “I think we should be seeing complex cases; with complex cases being defined as complex health or employment issues. We can be giving strategic advice to organisations in the UK, including the NHS and globally,” said Dr de Bono.
“I believe that occupational physicians, specialists in occupational medicine, should be providing clinical leadership within occupational health services. That is not the same as saying who runs it; the best person to run it should be running it. But I think the depth and the breadth of the training in occupational medicine should, as in other teams, be recognised. I’m not talking about managerial leadership here, I am talking about the clinical leadership in the specialty; I believe it should be an occupational physician.
“And we have got to talk about how we build the evidence base. Both the society and the faculty have two journals, which contain a lot of stuff that helps to build the evidence base. I refute the idea that there is no evidence base for occupational medicine. But it may be that it is not in a very systematic way translated into a pattern for practice.
“I think too often in occupational health we waste time arguing about who does what. I think if all the time spent worrying about who should do what and where could be translated into a model that we could all accept about the ways in which occupational health could be delivered, I think that would be hugely beneficial for us, for our specialty,” she concluded.
- Dr Raynal in her presentation highlighted that anyone interested in discussing these issues in more depth or getting involved in her campaign can email her on [email protected]
Government ‘not ruling out’ making occupational health mandatory for employers, says minister, Personnel Today, 28 June, 2018, https://www.personneltoday.com/hr/government-not-ruling-out-making-occupational-health-mandatory-for-employers-says-minister/
How the Brexit chaos robbed disabled people of another short-lived minister, The Independent, 14 March, 2019, https://www.independent.co.uk/voices/brexit-sarah-newton-resigns-vote-disabled-minister-no-deal-a8822881.html
Employers’ motivations and practices: a study of the use of occupational health services, Department for Work and Pensions and Department of Health and Social Care, April 2019. Available online at: https://www.gov.uk/government/publications/occupational-health-services-and-employers/summary-employers-motivations-and-practices-a-study-of-the-use-of-occupational-health-services
Understanding private providers of occupational health services: an interim summary of survey research, Department for Work and Pensions and Department of Health and Social Care, April 2019. Available online at:
A decade on, are we still ‘Working for a Healthier Tomorrow’?, Occupational Health & Wellbeing, 07 June, 2019, https://www.personneltoday.com/hr/a-decade-on-are-we-still-working-for-a-healthier-tomorrow/
Occupational health: the value proposition, Society of Occupational Medicine, May 2017. Available online at https://www.som.org.uk/sites/som.org.uk/files/Occupational_health_the_value_proposition.pdf
Improving lives: the future of work, health and disability, Department for Work and Pensions and Department of Health and Social Care, 30 November 2017. Available online at https://www.gov.uk/government/publications/improving-lives-the-future-of-work-health-and-disability