White Paper suggests OH practitioners can impact public health

The Government White Paper and consultation on health is an opportunity for OH practitioners to influence the business agenda, says Nic Paton.

For occupational health practitioners, arguably the key sentence within the Government’s public health White Paper Healthy Lives, Healthy People, published in December 2010, can be found on page 46 of the 100-page document. The statement could significantly change how ministers work with employers in the future.

When discussing how health and wellbeing can be improved throughout people’s lives, in particular how employers can improve health at work, the document states: “They [employers] can achieve this through establishing a strong cultural lead, strengthening management training in recognising and responding to the health needs of the workforce, and working more closely with others, particularly occupational health and primary care.”

It is not a statement that is going to change the world and, within many employers that offer access to OH services, this lead and link is already there and well established. But the fact that such a strong connection has been made between workplace culture, management training and health needs, as well as highlighting the different ways employees can access healthcare, is potentially very positive for the profession. However, as OH nurse educator Anne Harriss argues, the document could have gone even further in making the connection between OH provision and its benefits to workplace health.

“I was disappointed that it did not make it explicit that every worker should have access to occupational health provision. That, for me, was an omission,” explains Harriss, OH course director at London South Bank University.

“Having said that, there were a lot of good general recommendations and points within it, but it was just unfortunate it missed an opportunity to push every employer to provide some form of access to OH provision,” she adds.

In many respects, the document is innovative and imaginative. By pushing out power and ring-fenced budgetary responsibility for public health to local authorities it very much sits within the Government’s “Big Society” agenda. Equally positive is the recognition the White Paper gives to the ongoing Fit for Work pilots (see panel). Hopefully this is an indication that the vision behind these pilots will not grind into the dust in the current climate of austerity once they have been completed in the spring. Similarly, the recommendation that employers contract OH services only from those providers that have become fully accredited under the Faculty of Occupational Medicine’s voluntary Safe Effective Quality Occupational Health Service (SEQOHS) accreditation scheme has given a timely fillip to that initiative.

quotemarksIt would be good to see more emphasis on how work and work organisation can support public wellbeing policy”

Stephen Overell
The Work Foundation

There is a lot within the document that, if anything, raises more questions than it answers. The flesh on the bones of the proposed Public Health England – a new service to get people healthy – is somewhat lacking, as is the detail around the new Public Health Responsibility Deal, with its five “networks” on food, alcohol, physical activity, health at work and behaviour change.

Many commentators, such as Stephen Overell, associate director of policy at thinktank The Work Foundation, have also questioned if tasking local government with such a responsibility at this time, and to have it all up and running by 2013, is not overly ambitious given the budgetary and transformational challenges and upheavals the public sector currently faces.

Fit for purpose

Overell says: “More detail needs to be filled in about how the Government plans to work ‘in partnership’ with so many different agencies, not least employers. It has rightly highlighted the value of having work and the high costs attached to mental ill health and stress in terms of absence: these are big moves forward in terms of enhancing public health. Beyond initiatives such as Fit for Work, it would be good to see more emphasis on how work and work organisation can support public wellbeing policy and how occupational health can be enhanced.”

Transferring public health services to local authorities may sound like a good idea in theory but, even with a ring-fenced budget, councils may struggle to cope in the present climate, says Karen Jennings, head of health at Unison.

“Job losses add to stress, family breakdown and mental health problems. At the same time support services and welfare benefits are being axed, housing budgets are under severe strain, home care and elderly care is effectively rationed, all adding to the burden on our NHS,” she adds.

Nevertheless, the fact that the document is the first public health White Paper to explicitly make an “inextricable” link between physical and mental health is encouraging, argues Dr Andrew McCulloch, chief executive at the Mental Health Foundation. The recognition of the need to promote mental resilience in younger people and “active ageing” among older members of the population is also positive, he says.

But it will be important that the Government (and by inference employers) continues to invest in anti-stigma and anti-discrimination work “so we don’t continue with the access and rehabilitation problems that have compromised the success of public health and mental health services to date”, adds McCulloch.

For example, research covered in the January edition of Occupational Health suggested that the majority of employers still do not view depression as a viable reason to have time off work, with a poll of more than 1,800 employers by online therapy service Mentaline finding that one in five also admit they would be less likely to employ someone if they knew they had a history of mental illness.

The idea that employers could become “champions” of public health could gain some positive momentum with managers, according to healthcare provider and insurer Simplyhealth. “By promoting good health in the workplace employers can influence their employees’ wider health and wellbeing,” argues James Glover, sales and marketing director at the company.

Reaching the right people

The challenge is to reach out beyond those responsible employers who have already made this connection between productivity, engagement and public health. There will also be a challenge, as the paper has recognised, around the “what’s in it for me” argument – what incentives the Government may offer employers in return for taking on this public health role.

quotemarksIn order to really make an impact, businesses will need to be incentivised financially”

James Glover

“We believe that, in order to really make an impact, businesses will need to be incentivised financially,” stresses Glover, highlighting January’s 1% rise in insurance premium tax – and thereby reducing incentive in this area – as a good example of government rhetoric failing to be matched by actions.

There are also questions for longer-term issues about how, or in what way, this agenda could shape the future training of OH practitioners.

Soon after the announcement of the paper there was debate on web forums such as Jiscmail about whether it will necessarily lead to more collaboration or shared learning about occupational health and safety and hygiene programmes. Will it lead to greater multi-disciplinary working with mental health professionals or community mental health nurses?

As one poster on the Jiscmail site cogently put it: “We should not stand alone, but need to bring ourselves closer to others in similar/overlapping work such as occupational psychologists, specialists in organisational culture, human resources, ergonomists and so on. That way the proactive elements of our work may be recognised a bit more easily and it would be clearer about how we contribute to public health, especially when relating to the new public health strategy focus on wellbeing, self-confidence, resilience, the impact of environments and communities on individuals.

“We all know that the workplace is a community and part of our role as OHAs is to help make that community one which nurtures, engages, and encourages its members/employees. I feel that we are small group whose voice is not really heard or understood in the current position.”

Working together

There may in turn be challenges around how other health professionals are trained, something highlighted in December by the Royal College of Physicians of London, which argued that all physicians should be given training in identifying people at risk from increasing body weight and become better skilled at managing obesity.

OH professionals have always had a public health focus – it has been a key element of their work, even if technically located within a workplace setting. That will not change, but it will be interesting to see if an OH department’s public health remit within the wider community should change in response to the focus that the White Paper gives to the influence of communities and society on individual behaviours, self-esteem, resilience and confidence, suggests OH nurse Anna Harrington, manager of health and wellbeing specialist Harrington Enterprises.

She argues: “How OH professionals can work to influence communities and individuals in relation to self-esteem and resilience is, I think, something that could be potentially quite exciting. If we can start to make and demonstrate links between employee engagement, productivity and society to bring a business focus to public health – that could be very interesting. The workplace after all is a community.

“Occupational health needs to be involved and needs to be working more collaboratively with other specialists such as, say, occupational psychologists, ergonomists, health and safety professionals or HR. Even fostering a closer relationship with marketing might be a great idea if it helps get the message out more effectively about what OH can do and where it can help.

“The concern is that there is a perception that OH professionals are just wonderful at managing sickness absence and ill health within organisations. But in fact something like this is very much OH’s area too and practitioners need to be rising up and saying so,” she adds.

Key workplace-health-related points

Continuance of welfare and benefits reform to “make it pay” to go to work, including “working with employers to unleash their potential as champions of public health”.

Citation of Fit for Work pilots as a key element of helping central government to help people stay in work. These pilots will be evaluated, with the results expected to be published in late 2011, to allow the Government to “determine what works and in what circumstances”.

Further work is to be carried out on the fit note, including an increased amount of central government support to embed it within the NHS and implement an electronic version in GP surgeries.

Commitment to examining “the incentives in the sickness absence systems, with a view to reducing the numbers of people who fall out of work due to health conditions and end up on benefits”.

Emphasis that provisions in October’s Equality Act to prohibit employers from asking health or health-related questions prior to employment should result in occupational health professionals being able “to divert resources away from pre-employment health screening to preventative initiatives for all staff in the workplace”.

Recommendation that employers contract OH services only from those providers that have become fully accredited under the Faculty of Occupational Medicine’s voluntary SEQOHS accreditation scheme.

Government to continue to explore new models to support small and medium-sized enterprises (SMEs) in promoting workplace health, including using larger employers as examples of best practice, the NHS and wider community initiatives and programmes, in particular looking at how SMEs can promote the better management of chronic conditions in the workplace.

Under the Public Health Responsibility Deal, employers are to work to improve health outcomes in areas such as obesity, smoking, substance misuse and physical activity among employees, employees’ families and local communities.

Central government to do more to provide “the evidence and data needed to raise awareness among employers of the clear case for investing in the health of their employees”. This will include development and promotion of the Change4Life employee wellness programme, as well as the promotion of Business in the Community’s Workplace Well-being Tool designed to help organisations assess progress in this area and understand further steps.

All NHS organisations are to have a local health and wellbeing strategy put in place by 2011; this should include being more proactive in the quality of and speeding up on access to occupational health services as well as strengthening board accountability for the management of sickness and absence from work.


Other key points

Local government and local communities will be at the heart of the Government’s agenda for improving public health and wellbeing, with directors of public health (employed by local authorities) taking a strategic lead. Local health improvement functions are to be transferred to local government, including ring-fenced funding being allocated, from April 2013.

The Government is due to publish a response to plans for the setting up of new local statutory public health and wellbeing boards to “support collaboration across the NHS and local authorities”.

There will be the establishment of a new Public Health England public health service (located within the Department of Health), with ring-fenced public health funding, albeit taken from the overall NHS budget, with an estimated budget of more than £4 billion. This will be created from 2012 and will include the formal transfer of functions and powers from the existing Health Protection Agency and the National Treatment Agency for Substance Misuse.

More detailed announcements on changes to primary care trusts and Strategic Health Authorities to be set out in a series of planning letters during 2011.

During 2011 the Department of Health will publish documents on mental health, tobacco control, obesity, sexual health, pandemic flu preparedness, health protection and emergency preparedness.

Launch of a new “Public Health Responsibility Deal” early in 2011, including establishment of five “networks” on food, alcohol, physical activity, health at work and behaviour change. Announced forthcoming activities include agreements on reformulation of food to reduce salt, promotion of more socially responsible retailing and better information on food for consumers. The Government also intends to “develop” its existing Change4Life public health initiative.

The creation of a new National Institute for Health Research School for Public Health Research and a Policy Research Unit on Behaviour and Health.

Public health to be made part of the NHS Commissioning Board’s remit, with public health support for NHS commissioning nationally and locally, including “stronger incentives” for GPs to play an active role.

Forthcoming consultation documents are to be published on a public health outcomes framework, plus funding and commissioning arrangements for public health.

A review is to be carried out into the regulation of public health professionals, with the preferred aim to be, rather than statutory regulation, a system of independently assured voluntary regulation for unregulated public health specialists overseen by the Council for Healthcare Regulatory Excellence. This is something currently being consulted upon by the Government.

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