The Black Report: Practical implications

What are the implications of the Black Report recommendations?

Below we spell out the effects the proposals would have on:

OH nurses

Dame Carol Black’s report, Working for a Healthier Tomorrow, offers the prospect of occupational health as a ‘dynamic specialty’ and ‘a more rewarding role and exciting career’.

The report extends the remit of OH practitioners to cover not only employed people but those out of work and aims to extend access to all working age people.

OH nurses (together with physicians) should work in collaboration with public health managers, GPs and vocational rehabilitation practitioners on retaining employees in work, and early return to work after illness.

There will be opportunities for both nurses and doctors to work in the new ‘fit-for-work’ teams. This is likely to involve a different range of tasks than those of most OH nurses working for employers. These might include assessing fitness for work, providing advice and guidance, case management and rehabilitation. Different models of delivery should be tested in pilot projects. The aim is for them to work with people on incapacity benefits and those on other out-of-work benefits, as well as employees.

Health promotion will be an important role. The report notes that “the traditional role of being concerned with safety and controlling hazards in the workplace is already expanding to include the promotion of health and wellbeing”. Some nurses have already expressed concerns, for example in the online forum JISCmail, that the emphasis on health promotion is not a good use of the more advanced skills learned on occupational health degree courses.

OH nurses should include retention of staff in work and return-to-work as key outcomes of practice. Early intervention is a key objective, and nurses will be involved in areas such as assessments of the appropriateness of returning to work, assessing workplace risk factors and recommending adjustments or modifications.

Occupational health nurses will focus on strategy, management and more complex clinical assessments, while other tasks are delegated to occupational health technicians or other practitioners.

Practitioners will be required to have an accredited OH qualification. The report recognises that quality among OH practitioners is inconsistent and calls for “clear standards of practice and formal accreditation of all providers”. This appears to relate to the whole range of practitioners providing health and safety services.

Senior OH nurses could take a leadership role, for example in shifting attitudes, raising quality, workforce planning and delivering services.

Nurses and doctors will take responsibility for making the business case for investment in health and wellbeing to employers.

NHS Plus and equivalent services in Scotland should continue to have a role “to reach out to medium-sized businesses and offer a service on a commercial basis”.

OH nurses will communicate and share information with GPs using the new electronic ‘fit-notes’ which can be passed between them if patients agree. This may raise concerns about confidentiality of medical information among some nurse practitioners.

The Mental Health and Work report by the Royal College of Psychiatrists, which was commissioned alongside the Black report, calls for training of OH professionals in the detection and management of mental health problems. “this would include the recognition that mental health problems can present as physical symptoms and that mental health problems frequently co-exist with physical disorders.

 

OH physicians

Occupational health physicians’ leaders have already welcomed a leadership role in the new fit-for-work teams and industry. The report calls for “strong professional leadership” and notes that: “Traditionally this was a matter for occupational health and this specialty will always have a leading role.” However it adds that “rehabilitation and public-health specialties also have interests and expertise related to this area” suggesting that physicians cannot expect to have exclusive leadership on issues such as standards and delivery models.

The report seems to suggest some formal institute or other arrangement for leadership, but not the ‘Institute of Occupational Health’ which was proposed in the stakeholder consultations before the launch of the recommendations. It says: “Professional leadership will require the development of some form of over-arching framework that embraces all of these professions.”

Like nurses, OH physicians will be required to work in a broader collaborative and multidisciplinary service, as many already do.

The shrinking academic base needs to be tackled. OH physicians in the academic community have historically produced much of the research in occupational health, so it is likely this will be the case in future. The report notes that evidence for early intervention has focused on back pain, and that evidence is needed for those with other conditions, especially mental ill-health.

Developing service standards is a key role for physicians. The report notes that the Faculty of Occupational Medicine, NHS Plus and the Vocational Rehabilitation Association have recently undertaken initiatives to develop explicit service standards.

Health and work should be included in the core curriculum for undergraduates and postgraduates in medicine.

GPs

GPs will be required to adopt electronic ‘fit notes’ and overcome their natural caution to focus on what employees can do rather what they cannot. The electronic sick note “would allow GPs to compare standards of clinical practice with their peers and improve treatment, facilitate easier identification of regional local health issues, public health surveillance and service planning”.

There will be new options for referral under a new model of early intervention which should provide a minimum level of work-related health support to all employees.

GPs may have a role in developing ‘individual action plans for achieving recovery focused on return to work at the appropriate time as part of the plan’ for patients. The new fit-for-work service would also ensure that “those with more serious underlying conditions, often referred to as ‘red-flag’ conditions, would be referred onwards at the earliest possible opportunity”.

Case managers will update GPs and “discuss adaptations or changes to the patient’s work situation that might include a phased return to specific restricted duties, flexible working or a change to their job role and responsibilities”.

The fit-for-work team would have to be placed in or close to primary care. Different models for delivery could be trialled, and they could be based in health centres and cover a number of GP practices.

GPs will be invited to join a register showing they have an interest in health and work.

Employers

Employers should understand the business case for investment, and develop a robust model for measuring and reporting on the benefits of employer investments in health and well-being. They should also use the measures developed by the government to report on these benefits.

Employers should play their part in tackling the stigma around ill health and disability.

A consensus agreement is under development for employers, along the lines of the one launched in March 2008 for health professionals.

Employers should raise awareness of what makes a ‘good job’, for example one which gives employees a sense of control over work-flow, and matching effort with reward.

There should be early, regular and sensitive contact with employees during sickness absence.

All employers should have a sickness absence management policy – currently 40% do not.

Larger organisations should support their contractors and suppliers on workplace health issues.

Employers should understand and exploit the links between health, employment and productivity, as identified by the Work Foundation, the CBI and the Chartered Institute of Personnel and Development.

Employers should exploit the workplace to promote health and wellbeing. They should ‘recognise the opportunities offered by the workplace for the provision of facilities and dissemination of advice on how to improve and maintain health.”

“Preventive measures need to be tailored to the industry sector, rather than adopting a one-size-fits-all approach.”

The public sector should lead by example.

Employers should capture and use data more effectively to manage workplace health issues. “The ‘fit note’ would enable employers to identify patterns of absence within particular departments or roles and deal with possible health problems.”

HR managers

HR would play a key role in all of the recommendations that relate to employers in general.

HR has an important role in promoting working practices that raise levels of health and wellbeing. The report cites research published by the Work Foundation which found that employees are likely to have worse health if: employment is insecure work is monotonous and repetitive workers have little or no automony, control and task direction there is an imbalance between effort and reward so that workers feel exploited or ‘taken for granted’ (wider than just the wage packet) there are no supportive social networks there is an absence of procedural justice in the workplace, i.e. workers cannot be confident they will be fairly treaded by their employer.

Line managers should be supported to understand that the health and wellbeing of employees is their responsibility, and should be willing to take action when health and wellbeing are at risk.

Managers should be trained to manage health at work. Lord Leitch’s Review of Skills 2006 recommends that training should include management skills in sickness absence, as well as management of the health and wellbeing of the workforce more holistically. The development of a health standard in Investors in People will provide a benchmark for employers.

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Line managers

“Line managers have a key role in ensuring the workplace is a setting that promotes good health and wellbeing. Good management can lead to good health, well being and improved performance. The reverse can be true of bad management. The manager is the key agent of change.”

Line managers also have a role in identifying and supporting people with health problems to help them to carry on with their responsibilities, or adjust responsibilities where necessary.

The Royal College of Psychiatrists’ report published to support the Black report calls for “training of workplace line managers in how to recognise mental distress or ill-health and how to respond in ways that do not lead to unnecessary exclusion from the workplace,” the report says.

They should “support people who have, or are at risk of developing, health conditions. Support may mean adjusting or adapting working practices, patterns or job roles where appropriate to do so”.

Psychological therapists, counsellors

The government is trialling increased access to practitioners in the Increasing Access to Psychological Therapies pilots, and the report recommends this is in mental health at work policy.

Talk therapies will “integrate health support with employment skills programmes, including mental health where appropriate”. Counsellors will have a role in the fit-for-work teams, providing advice and support for social concerns such as financial and housing issues.

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Case managers, rehabilitation services

Rehabilitation practitioners have a role in professional leadership alongside OH.

Case managers or support workers will help the individual navigate the system and facilitate communication between the individual, their employer, their GP and other clinicians. In the ‘hub-and-spoke approach’ of the new fit-for-work teams in the NHS. A case manager will navigate a patient through a personally-tailored programme of support and formulate an individual action plan.

The case manager would regularly update the patient’s GP.

Explicit service standards must be developed for vocational rehabilitation.

Trade unions

Trade unions must seize the opportunity to champion health and wellbeing in the workplace. It was widely reported that union hostility led to the failure of pilot projects to give occupational health practitioners responsibility for sickness certification in 2007 (link). Unions should shift from protecting the employee’s right to go sick and receive pay and benefits to help them get them back to work.

Unions should play an expanded role in measuring and reporting the benefits of employer investment.

Government

The government is set to respond to the recommendations of the Black report in the summer of 2008

Recommendation two asks the government to initiate a business-led wellbeing consultancy service.

Recommendation four asks the government to launch a major drive to promote understanding of the positive relationship between health and work.

Recommendation seven asks ministers to pilot a fit-for work service.

Government should monitor the baseline set out in the report and carry out “an extensive programme of research to inform future action with a comprehensive evidence base and increased cross-governmental effort to ensure progress”.

“The government should work with employers and representative bodies to develop a robust model for measuring and reporting on the benefits of employer investment in health and wellbeing.”

The government should review anomalies in the tax system. For example, a larger organisation can build a gym on site without incurring additional tax liabilities, but when smaller companies subsidise membership of external gyms for employees it is taxed as a benefit.

Government needs to ensure that the commissioners of health services understand the importance of tackling working age ill-health and the interventions. Simple guidance for commissioners would help.

“Governments’ intention to draw up a mental health and employment strategy should include a wide-ranging, systematic review and evaluation of current policies and their effectiveness for those with mental health problems.”

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