The health and wellbeing of the UK working population, about 28 million people, is crucial to the health of society as a whole. Public health is the discipline concerned with analysing and improving health in populations – ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’. This definition reflects the essential focus of modern public health.1
Surveillance and assessment of the population’s health and wellbeing
Promoting and protecting the population’s health and wellbeing
Developing quality and risk management within an evaluative culture
Collaborative working for health
Developing health programmes andservices, and reducing inequalities
Policy and strategy development and implementation
Working with and for communities
Strategic leadership for health
Research and development
Ethically managing self, people and resources.
The International Labour Organisation (ILO) and the World Health Organisation (WHO) share a common definition of occupational health, which was first adopted in 1950 and revised in 1995.3 Its overall aim, with a focus on the health of the working population, dovetails with that of public health. “Occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention among workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarise, the adaptation of work to man and of each man to his job.”
Improving the health of the working population contributes to improving the health of the whole population. The National Institute for Health and Clinical Excellence (Nice) has developed public health guidance which makes recommendations for populations and individuals on activities, policies and strategies that can help prevent disease or improve health. The guidance may focus on a particular topic, such as smoking and obesity, a particular population, such as the working population, or a particular setting, such as the workplace.
The most recent public health guidance, relevant to the working population (March 2009) focuses on ‘Long term sickness absence and incapacity for work’.4 Recommendations complement the proposals outlined in Dame Carol Black’s review of the health of Britain’s working age population Working for a Healthier Tomorrow (Health, Work and Wellbeing Programme 2008).5 and in the government’s response.6
Nice public health guidance is aimed at ‘public health professionals and practitioners and others with a direct or indirect role in public health within the NHS, local authorities and the wider public, voluntary, community and private sectors. The aim is to help them achieve the targets set out in the 2004 public health white paper Choosing Health: making healthy choices easier‘.7
Public health and occupational health practice have common aims, namely:
Health improvement, including surveillance, monitoring of specific diseases and risk factors and lifestyle issues such as smoking and alcohol
Health protection, for example exposure to environmental hazards
Healthcare including service planning, equity, audit and evaluation, for example.
It makes sense, therefore, for occupational health professionals to have an understanding of the bigger picture and context in which health problems arise on the one hand and how they can be influenced on the other.
All European countries have substantial socio-economic inequalities in health, but the UK has probably the largest. Unemployed people and those in unskilled work have a shorter life expectancy and experience more ill-health. Despite the 1998 Independent Inquiry into Inequalities in Health,8 to date only limited attention has been paid to the wider social determinants of health, which include unemployment, low incomes and stressful work environments.
Integration of occupational health within the broad framework of public health would allow for a more comprehensive appreciation of health inequalities and the problems that need to be addressed.
Relevant historical trends in the UK
In 1974 public health was transferred from local authority responsibility to the NHS. Occupational health remained outside the NHS. Thus, only a minority of UK workforces had access to occupational health, mainly those working for large organisations with their own in-house occupational health services. The vast majority, working for SMEs or micro enterprises, had little or no access to occupational health.
Some research suggests that the percentage of SMEs providing occupational health support could be as low as 6%, probably less than 2% for micro enterprises – perhaps not surprising given that about 96% of small enterprises employ fewer than 20 people. The labour turnover in small firms is high, the average survival for the smallest being only two to three years. There is a clear association between unemployment and ill health, but for those who are employed, particularly those on low incomes, the risks to health are less well recognised.9 Despite the 1974 Health and Safety at Work Act, it is clear that occupational health provision has not reached millions of people working in small companies, on low incomes, where there is widespread job insecurity. Health inequalities have become more apparent over the years. There are strong links between employment and the health of local communities.
As stated in the Choosing Health White Paper,7 which focuses on the role of the healthy workplace in promoting the general health of a community, “it is in all our interests to take forward action to support people into employment and improve opportunities for good health in the workplace. Income from employment increases the potential for people to make healthy choices; employees can benefit personally from being in a healthy workplace… and society benefits from high employment and a fit and productive workforce.” Thereby simultaneously reducing social and health inequalities.
In the 1970s, specialist training was established for doctors working in public health and occupational medicine through two new Faculties of the Royal College of Physicians. The Faculty of Public Health Medicine (initially the Faculty of Community Medicine, now the Faculty of Public Health) was set up in 1974 and in 1978 the Faculty of Occupational Medicine was established. Specialist training was based on the medical model. The fact that these two medical disciplines developed along separate pathways has led to little integration over the years. More recently the Faculty of Public Health has extended entry to non-medical people working in the public health field in recognition of its multidisciplinary nature.
Specialists in public health come from a wide variety of backgrounds: economists, doctors, managers, nurses, and work in a wide range of settings. These include all parts of the NHS, from primary care trusts to strategic health authorities, and outside the health service including government, local authorities and universities.
Occupational health nurses with an interest in public health can now take a specialist course in Public Health Nursing with the aim of preparing practitioners to take a proactive role in employee health management and develop the role of the OH nurse in a public health agenda10
Development in other countries
The situation is different outside the UK, so that in the Netherlands, Finland and other European countries, and in the US and Canada, there are Schools of Public and Occupational Health. There is common ground in the core curriculum, facilitating a population perspective on health and health care, including epidemiology, information sciences and statistics.
An innovative course at the Canadian Institute for Population and Public Health provides a multidisciplinary graduate fellowship programme whose goal is to develop creative evidence-based strategies to solve public, environmental and occupational health problems. The focus is the prevention of disease rather than a reactive, medical approach to health problems. It is worth remembering that some of the largest gains in life expectancy in the last century resulted from primary prevention of disease and injury such as improved conditions in the workplace.
An era of rapid change in the workplace
Since the1980s there have been enormous changes in work environments. The old industrial diseases are now rarely observed. The infrastructure of the workplace is continually changing, as are work practices in all types of organisations. Markets have become global, competition has increased, work has become increasingly flexible and even previously secure industries such as banking have been overwhelmed in ways that were inconceivable a few years ago.
A pattern of unemployment, redundancy and frequent job change has become the norm for most people. Manufacturing industry has steadily declined and more than two-thirds of those employed now work in the service industries. There has been a steady increase in the number of people in part time work, particularly women, and in shift-work and so called flexible working.
Occupational health provision in the UK has never been comprehensive, as already indicated, and at best, might be described as patchy. The public sector has fared better in that workforces are more likely to have access to occupational health advice than those in the private sector. NHS Plus provides occupational health for NHS employees and in some areas offers services to local businesses.
However, as stated previously, there are problems of access for the very large numbers of small workplaces where labour turnover is high. For these workers and also for the self employed, primary care is usually the main source of advice.
The involvement of primary care as a key partner in occupational healthcare was spelled out last year in Dame Carol Black’s Review of the health of Britain’s working age population.5“The development of an integrated approach to working age health requires occupational health to be brought into the mainstream of healthcare provision. Its practitioners must address a wider remit and embrace closer working with public health, general practice and vocational rehabilitation in meeting the needs of all working age people.
“Clear leadership will be required from occupational health and vocational rehabilitation communities to expand their remits and work with new partners in supporting the health of all working age people,” it said.
Effectively this will involve a paradigm shift for occupational health – no longer an outsider, but an important player in the mainstream of healthcare and public health. It will mean occupational health advisers will be found in primary health care centres/general practices, in departments of public health providing specialist support for directors of public health and as key players in establishing community-based links with the proposed National Centre for Working-Age Health and Wellbeing.6 Occupational health practitioners will need to collaborate with the new health, work and wellbeing co-ordinators who will “stimulate action on health, work and wellbeing in their areas, offering advice and support to help local partnerships and engagement with smaller businesses in particular.”6
Principle objectives identified in the review of the UK’s working age population:
The prevention of illness and promotion of health and wellbeing
Early intervention for those who develop health conditions
An improvement in those out of work so that everyone with the potential to work has the support they need to do so.
It was felt that a shift in attitude was necessary to ensure that employers and employees recognise not only the importance of preventing ill health but also the key role the workplace can play in promoting health and wellbeing.
The review found considerable evidence that health and wellbeing programmes produced economic benefits across all sectors and sizes of businesses. Organisations that improve their working environments by organising work in ways that promote health find improved employee morale and that adverse health-related outcomes decrease, including injuries and absence, thus making a strong business case for creating a healthy workplace.11
Workplace potential to improve health
Health and wellbeing is not solely a medical/health issue and line managers have a role in identifying and supporting people with health conditions to carry on at work or make adjustments for them.
As emphasised in the review, leadership is key to a healthy workplace. It is an important setting for preventive activities since those of working age are likely to spend a large proportion of their waking hours at work. The workplace therefore has considerable potential and it has a key role to play in achieving the WHO’s European Health for All targets12 and the four main objectives:
Greater equity in health
The promotion and facilitation of healthy lifestyles
A reduction in the burden of preventable ill health
A re-orientation of health care systems.
The common mental health problems such as anxiety or depression and musculoskeletal disorders are major causes of sickness absence. There is huge scope to improve awareness, early identification and appropriateintervention.
Lifestyle factors affecting health and proactive health policies
It is increasingly difficult to distinguish between illness caused by work and illness due to other causes. Many common diseases are directly linked to lifestyle factors. There are no clear boundaries, and many health problems develop over a long timescale and have multiple causes, for example cardiovascular disease. This broader view of occupational health allows for factors related to lifestyle to be tackled, for example, alcohol and substance misuse. The overall aim is to promote the general health of workers as well as to optimise working conditions so that work is better adapted to the workers in terms of both their physiological and psychological needs.
The overall aims should be:
To provide a safe and healthy workplace
To promote optimal physical and mental health of all employees
To strengthen the relationship between health and productivity so that employees can contribute effectively to the organisation’s goals and also enhance their own personal wellbeing.13
Policies on health promotion should be developed alongside those on health protection. A proactive organisation will formulate specific policies on alcohol and substance misuse, smoking, mental wellbeing and minimising stress as well as policies aimed at heart disease prevention, including advice about healthy eating and physical activity.
Education and training on mental health
As already mentioned, mental health problems have a high prevalence in the workplace but there has been relatively little research about the effectiveness of interventions that assist people to remain in work or return to work. There is a need to educate, train and raise awareness about issues that relate to work and mental health. Training of occupational health professionals in the detection and management of mental health problems is a priority.14
The very large burden of minor mental health problems that go largely unnoticed since they do not result in referral to specialists, contribute significantly to poor work performance. The scope for improvement in this area is enormous and has the potential to improve not only the health of the individual but also that of the organisation as a whole.
The assessment of long-term health problems is also important. Liaison with an employee’s own doctor is crucial in order that the occupational health adviser can provide essential guidance for management on fitness for work and rehabilitation.
Links with other organisations
Proactive occupational health requires links to be established with many outside organisations and specialist resources, such as vocational rehabilitation services. Occupational health should not operate in isolation but rather at the centre of a network of services which can be made accessible to the organisation and thus bring to it a range of different skills. Occupational health should form part of a coherent public health strategy for achieving optimal health, wellbeing and productivity in the working population.13
Dr Jenny Lisle is an independent consultant in public and occupational health.
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1 Acheson, Sir Donald (1988) Report on Public Health in England
2 The Faculty of Public Health, The 10 areas for public health practice
3 WHO/ILO definition of occupational health (adopted 1950, revised 1995)
4 Nice public health guidance 19, Management of long term sickness absence and incapacity for work
5 Black, Dame Carol (2008) Review of the health of Britain’s working age people, ‘Working for a healthier tomorrow’
6 Government’s response to Review (2008) ‘Improving health and work: changing lives’
7 DoH Choosing health: making healthier choices easier (2004)
8 Independent inquiry into inequalities in health report (1998) The Acheson Report
9 Faculty of Public Health (1995) Guidelines for Health Promotion in the workplace
10 London South Bank University (2008) BSc (Hons.) Public Health Nursing (Occupational Health Nursing)
11 Faculty of Public Health & Faculty of Occupational Medicine (2006) Creating a Healthy Workplace
12 WHO (1993) Health for All Targets. The Health Policy for Europe
13 Lisle J (2001) Organisational health: a new strategy for promoting health and wellbeing in ‘Health Promotion’
14 Report for the National Director for Work and Health (2008) Mental Health and work