Health and Safety
Executive / Commission
About HSE
1. Introduction
3. The meaning of 'Occupational health' and 'Occupational health support'
6. Occupational health support in the European Union
7. Impact of changing work patterns on occupational health provisions
8. Small and medium enterprises (SMEs)
8.1 What are SMEs?
8.4 The needs of SMEs for occupational health support
8.8 Priority needs of SMEs
9. The needs of larger companies
10. The needs of workers and others
11. Prioritising occupational needs
12. Objectives
13. Tackling health inequalities
13.7 The need for partnerships at local level
14. Legislation
15. Self auditing/self assessment of health and safety performance
16. Other incentives
16.2 Costs and Benefits
16.6 Employers' Liability insurance
16.7 Industrial injury benefit
16.8 Tax relief
16.9 Levy on employers
16.13 Reduction in business rate
16.14 Awards for health and safety performance
16.16 Extending the Investors in People standard
17. Raising the profile of occupational health through training and education
18.2 Approach to delivery of occupational health support
19. HSE guidance
21. The role of National Health Trusts
21.5 Potential problems with primary and NHS care
23. Problem solving and self help for employers/workers
23.2 Telephone helplines and information technology
23.5 Advice from good neighbours and intermediaries
23.8 Helping people who are difficult to reach
24.3 Consultation and involvement
25 Framework for putting delivery of occupational health support together
26 Evaluation
Summary, conclusions and recommendations of the OHAC Occupational Health Services Working Group
At the start of a new millennium we are still faced with the centuries' old problem of illness caused by work. The nature of occupational illness has changed but its incidence remains stubbornly widespread. This can lead to diminished quality of life, loss of livelihood and business failure. Shockingly, such illness can be avoided. With effective occupational health support and advice, health risks at work can be managed in ways which need not be costly or difficult and workers who have already been made ill, from whatever cause, can be helped to remain in work.
We are all becoming more health conscious and our understanding of the factors that contribute to illness and its avoidance is growing. The work environment is an ideal setting to promote the health of workers, and occupational health in its broadest sense can make a significant contribution. Occupational health support can also help employers to provide more working opportunities for disabled people.
Changing patterns of employment mean that an increasing proportion of the working population are employed in small enterprises where there is no ready access to occupational health support. There are real challenges in making such support and advice easily available to hard pressed employers and workers in small enterprises. Practical solutions are needed and the Recommendations in this Report offer these.
Publication of the Report, prepared in 1999 to advise Ministers, has been deferred to enable it to be published alongside the occupational health strategy for Great Britain to which the Report makes a key contribution.
Inevitably there have been developments since the Recommendations of the Occupational Health Advisory Committee (OHAC) were put into context in the introductory paragraphs of the Report. To mention a few:
The Recommendations will form an important plank of both the new occupational health strategy for Great Britain and the Government's public health agenda. In particular, pilot projects to fulfil the Recommendations will feed into all the action programmes under the new occupational health strategy.
By working together in partnerships as recommended in this report we can bring about healthier working lives for everyone.
1.1 This report sets out the conclusions and recommendations of the Occupational Health Services Working Group (OHSWG) of the Occupational Health Advisory Committee (OHAC), which were adopted by OHAC on 12 March 1999, on how to improve access to occupational health support, particularly for people at work in small and medium enterprises (SMEs). The report is in four parts as follows (and includes a summary of the conclusions and recommendations at the end of Part 4):
1.2 The work of the OHSWG has been carried out in response to an invitation from Ministers to the Health and Safety Commission (HSC) to undertake a programme of work, in liaison with the Department of Health (DoH) to advise the Government on ways of driving forward a framework of occupational health support aimed at improving access for everyone, but especially people who work or have worked in SMEs. This reflects Ministers concern that lack of access to occupational health support contributes to health inequalities within the adult population. As this is a response to Ministers with portfolios for England, the recommendations have been made with England in mind but we hope that similar issues can be considered in the context of Wales and Scotland in due course.
1.3 The OHSWG's work has been taken forward at the same time as work to develop the public health agenda through the White Paper flowing from the Green Paper, 'Our Healthier Nation', as well as the HSE's ongoing work to develop recommendations for a long term occupational health strategy for Great Britain. It had earlier been anticipated that these projects could be taken forward in such a way that this report could take on board their conclusions. At the time of writing, however, the White Paper and the long term occupational health strategy are still being developed and therefore this report cannot reflect those conclusions.
1.4 The OHSWG has focused on occupational health as the latent onset of work-related symptoms of ill health means that even some employers who manage safety issues effectively may overlook the prevention of longer term ill health. But many of the ideas and recommendations in this report will apply equally to safety issues as well as health.
1.5 The main overarching conclusions reached by the OHSWG which have informed all its recommendations are:
(a) prevention of ill health at work and amelioration of the effects of health on work, e.g. through rehabilitation, are essentially management issues and whilst professional occupational health support may be required, this is not inevitably the case in all circumstances. The key will be to ensure that employers and managers have access to a point of enquiry that can either suggest solutions or signpost employers and managers to the appropriate level of advice;
(b) strategies to remove occupational health inequalities and improve access to occupational health support will not succeed, unless further action is taken to improve employer and worker awareness of when such support is needed;
(c) delivery mechanisms for occupational health support should give priority to the prevention of health risks at work and the issues that arise from the effects of health on work e.g. non-work related illness compounded by work, and rehabilitation;
(d) there is no one solution that will meet the occupational health support needs of everyone; flexibility is the key to delivery mechanisms;
(e) there is a wide range of mechanisms, many involving partnerships, that should be pursued to raise awareness of occupational health issues, and encourage and facilitate the delivery and use of occupational health support.
2.1 The HSC decided, on 10 February 1998, that work to produce recommendations to Ministers to improve access to occupational health support should be undertaken by the Occupational Health Advisory Committee (OHAC) which advises the Commission and Ministers on occupational health issues. At its meeting on 16 March 1998, OHAC appointed a Working Group on Occupational Health Services (OHSWG) with the terms of reference set out in
Appendix 1. The Working Group met six times i.e. on 13 May, 29 July, 26 August, 2 November 1998, 29 January and 19 February 1999.2.2 The constitution of OHAC allows for the co-opting of members who do not sit on OHAC itself. It was important that the Membership represented as many relevant interests as possible without making the Group unwieldy. Therefore, in addition to OHAC members and assessors, OHSWG members included representatives of small and medium enterprises, health promotion interests, ergonomics and the NHS. A complete list of members is given at
Appendix 2.2.3 In fulfilment of the Ministers' invitation described in paragraph 1.2, the work has been carried out in close liaison with the Department of Health (DoH) which was represented on OHSWG, in line with Government determination to address health inequalities in a holistic manner. The OHSWG's recommendations have been informed, in part, by the joint HSE/DoH Working Conference "Towards Occupational Health Solutions" held on 6 July 1998 which considered the needs of SMEs for occupational health support and the means of fulfilling those needs. This was attended by an invited audience of some 60 delegates representing a variety of occupational health providers and professional bodies, SMEs, trades unions, insurers, local health authorities, the Health Education Authority, the NHS, city Occupational Health Projects and others. Tessa Jowell MP, then Minister for Public Health, and Angela Eagle MP, then Minister with responsibility for Health and Safety both spoke at the conference. The conclusions of delegates to the Conference are set out in
Appendix 3.2.4 In order to test the ideas of both Conference delegates and the OHSWG itself, Members agreed that MORI should be commissioned to undertake a limited telephone survey of SMEs to assess awareness of occupational health issues, their needs for advice, the preferred way of meeting such, their willingness to buy in support and their views on hypothetical ways forward such as annual safety returns or legislation to specifically require employers to engage occupational health support. The results are noted in the report, under the relevant sections and MORI's key findings are set out in
Appendix 4. Because of the relatively small sample, the results should be taken as indicative rather than conclusive.2.5 The workplace is recognised in the Government's public health agenda as an important setting for the improvement of health and the removal of health inequalities. The work of the OHSWG will therefore be relevant to the strategies arising from the Green Papers, 'Our Healthier Nation', 'A Healthier Scotland, and 'Better Health, Better Wales'.
2.6 The OHSWG's conclusions are likely to dovetail with HSE's long term strategy for occupational health, particularly in relation to the stimulation of demand for occupational health support and the shorter term mechanisms that will deliver such support. The extent of this, however, will not be known until the analysis of the response to the occupational health strategy discussion document is completed. Nevertheless, the OHSWG's conclusions are relevant to the aims in the discussion document on providing sound advice, and raising occupational health awareness. The final strategy will be able to draw from some of the pilot studies and ideas proposed in this report.
3.1 The following paragraphs set out the OHSWG's views on what constitutes occupational health and occupational health support, which form the basis of the Report's recommendations.
3.2 The term 'occupational health' conveys different things to different people. For some, it means simply the prevention and treatment of illness that is directly related to work, in which health education has no place. Others will emphasise fitness for work issues separately from health and safety. However the impact of any sickness absence on SMEs and their employees does not brook such fine distinctions. In those terms, it is of little importance whether the sickness is the result of an accident at work, long term exposure to risk or the conflicting demands of home and work. Only a holistic approach can make a difference to health inequalities. The recommendations on this report are therefore based on the broad view that occupational health can embrace:
(a) the effect of work on health, whether through sudden injury or through long term exposure to agents with latent effects on health, and the prevention of occupational disease through techniques which include health surveillance, ergonomics, and effective human resource management systems;
(b) the effect of health on work, bearing in mind that good occupational health practice should address the fitness of the task for the worker, not the fitness of the worker for the task alone;
(c) rehabilitation and recovery programmes;
(d) helping the disabled to secure and retain work;
(e) managing work related aspects of illness with potentially multifactorial causes (e.g. musculo-skeletal disorders, coronary heart disease) and helping workers to make informed choices regarding lifestyle issues.
3.3 The OHSWG includes the term 'occupational health services' in its title but it soon became clear that this was too narrow a description of the kind of help that employers needed to fulfil in order to protect the health of their employees. Although there is no generally accepted definition of what constitutes an occupational health service and no clear single form of practice, such services are traditionally understood to be medically based and led by doctors or nurses. Many existing providers of occupational health services, particularly in the private sector are now able to field multidisciplinary teams including e.g. occupational hygienists, ergonomists, psychologists, health and safety specialists and counsellors etc. but such teams are still likely to be led by a doctor or nurse. However what many SMEs need in practice is simple, sector specific guidance on practical measures to reduce exposure to hazardous agents, advice on enabling workers with health problems to continue working, together with information they can pass to their employees about ways of keeping healthy. Such advice may be obtainable from engineers and other technicians, trade associations, suppliers of material and equipment and safety representatives. Many workers in small businesses are likely to remain reliant on primary care, trades unions and safety representatives for advice. Therefore this report uses the expression 'occupational health support' throughout to indicate the full range of advice that SMEs and workers may need to tap into.
3.4 Good occupational health practice (as fostered by good occupational health support) is one of the factors that should lead, in the longer term to positive outcomes for workers and businesses alike, in terms of a good quality of life inside and outside work, the social and material advantages of work, reduced sickness absence, higher productivity, a good, responsible image for individual businesses and greater national wealth creation.
4.1 As set out in the terms of reference at Appendix 1, the OHSWG's remit was to recommend ways in which access to occupational health support could be improved for everyone, whatever their place of work. As discussed in Part 2 of this report, there are no grounds for complacency even with regard to larger enterprises. Some of the mechanisms discussed will be applicable to any organisation, large or small, but the Working Group has paid particular attention to those who are least likely to have ready access to occupational health advice and those who have specific needs i.e.
(a) SME employers who for reasons of size, finance or geography cannot buy in appropriate occupational health support or lack the motivation to do so, and their employees;
(b) self-employed persons;
(c) workers in need of rehabilitation and recovery programmes;
(d) workers who may be disadvantaged through reasons of youth, gender, ethnicity or disability;
(e) the unemployed, the retired, and potential returnees.
4.2 The OHSWG was charged with looking at ways in which access to occupational health support could be improved. Discussions soon established that simply increasing the quantity, quality or range of delivery mechanisms for occupational health support would not be sufficient to bring about such improvement. Employers and workers first need to be able to identify when such support is needed and be motivated to use it. This report therefore makes recommendations aimed at improving awareness of occupational health needs as well as means of delivering support.
5.1 This Part sets out the context in which the Working Group discussions took place, in terms of the existing legislation, international factors, and the impact changing patterns of employment have had on current levels of provision.
5.2 The Health and Safety at Work etc. Act 1974 (HSWA) places a wide ranging duty on employers to protect the safety, health and welfare, of their employees. Regulations made under the HSWA and other legislation (see Appendix 5 to this report) place specific duties on employers relating to e.g. risk assessment, health surveillance, managing health in certain sectors, fitness for work in occupations entrusted with public safety, protecting the vulnerable and employing the disabled. However, in contrast with legislation in certain other EU Member States, none of these provisions place a duty on employers to provide or buy in occupational health services. Instead, the Management of Health and Safety at Work Regs. 1999 (the 1999 Regs.) require employers (with certain exceptions) to appoint competent persons to fulfil their statutory responsibilities. The nature of the competency is purposely not defined so as not to constrain the nature of that advice which may need to come from occupational health services, but could equally come from e.g. ventilation engineers, plant designers etc. The 1999 Regs. and associated Approved Code of Practice make it clear that the preferred way of complying is to appoint people from within the workforce. In practice this may be difficult for very small businesses with few employees and little knowledge of what level of support is needed.
5.3 Consultations on occupational health problems need not always be external, or conducted with specialists. Consultation with employees will help to motivate staff and promote awareness of health and safety issues. The Safety Representatives and Safety Committees Regulations 1977 and The Health and Safety (Consultation with Employees) Regulations 1996 require employers to consult with employees on health and safety matters. In many cases, it is the workers themselves who know most about their immediate working environment and the types of risk to which they are exposed.
5.4 HSWA also places duties on employees to take reasonable care for the health and safety of themselves and others, to co-operate with employers in compliance with the latters' obligations, and not to interfere with or misuse anything provided in the interests of health, safety or welfare.
5.5 The Disability Discrimination Act 1995 (DDA) requires employers with 15 or more employees to treat disabled persons equally with non-disabled persons in all employment matters and make any reasonable changes to the premises, job design etc. that may be necessary to accommodate the needs of disabled employees. DDA extends the definition beyond deafness, blindness, mental illness and physical impairment, to include severe disfigurement as well as progressive conditions such as AIDS where disability develops some time after first diagnosis. Excessive selection procedures to exclude the disabled may be an offence under DDA. Occupational health support can help employers to avoid acting in a discriminatory manner .
6.1 Reg. 6 of the 1992 Regs. implements the requirement contained in Article 7 of the Framework Directive 89/391 which requires employers to designate one or more workers to carry out activities related to protection from and prevention of occupational risks. If there are no competent persons 'in house', employers must enlist competent external services. The nature of the competency is not specified.
6.2 The Framework Directive was significantly influenced by ILO Convention 161 on Occupational Health (see Appendix 6) and is pivotal to the EU's health and safety legislation. The Directive has been implemented in all Member States but, as is usually the case, the methods of implementation have reflected national practices and legal procedures. An EC Ad Hoc Working Group (AHG) on Multidisciplinary Protective and Preventive Services, on which the UK is represented by the Chair of the OHSWG, has been given the task of examining the implementation of Article 7 of the Framework Directive and preparing a draft opinion for the EC Advisory Committee on Safety, Hygiene and Health Protection at Work. A meeting of EU Government representatives in September 1998 agreed that there should not be a further directive.
6.3 European models for the provision of occupational health support vary from monodisciplinarity at one end of the spectrum, (as exemplified by the French system of services firmly grounded in occupational medicine and mandatory medical examinations) to the multidisciplinary models of Scandinavia. Each system reflects the history and culture of the individual country concerned rather than an attempt to introduce a uniform EU model. All the member states' occupational health arrangements have their flaws and attributes and none would seem to offer a perfect model. Monodisciplinarity can lead to the wastage of resources on annual 'medicals' that in many circumstances would be better spent on prevention, and leaves little room for a non-medical approach. Multidisciplinarity offers a better model but in some of the countries where it is mandatory, links with public health and, sometimes employees, remain weak. New legislation in the Netherlands, aimed at overcoming escalating sickness absence problems, means that all employers have to either secure the assistance of a certified occupational health unit or establish their own. However there is no penalty for non compliance except through civil litigation. The mandatory approach has led to fierce competition between the (privatised) providers with attendant concerns for quality of service and some providers going to the wall.
Finland is often seen as the leader in occupational health expertise. Its legislation obliges employers to organise and finance occupational health services for all workers irrespective of the size of the enterprise. Up to 50% of costs can be reimbursed through national sickness insurance if the service meets certain conditions regarding competence and worker consultation. Many services are bought from municipal health centres but employers are free to use private providers or set up in-house services.
7.1 Rapidly evolving changes in the British economy have led to a number of perceived inequalities in occupational health. The comparatively high level of use of occupational health professionals or health and safety specialists by the public sector means that overall, almost half the total workforce has access to some form of occupational health advice, even though this may be fairly remote from the workplace. Even allowing for some diminution in public sector occupational health support, following contractorisation, the picture is very different in the private sector. Here, only some eight per cent of establishments make use of the services of a health professional. (see Appendix 7).
7.2 Access to occupational health services has never been universal in private sector employment but a higher proportion of workers than now were once covered by employer's 'in-house' services. The decline of large manufacturing companies and the paternalism sometimes associated with such organisations, contracting out and 'down sizing' have all contributed to the decrease in the number of people covered by in-house services. It is now more usual for companies and large public sector organisations (except the NHS), which use occupational health services, to buy them in. Many contractors offer good services but their distribution is uneven, particularly outside major conurbations. Indications are that most smaller companies either do not use occupational health support at all or rely on GPs or nurses, some of whom are not trained in occupational health and therefore may not provide an adequate level of support. At the same time the DDA (see para 5.5) may present new challenges to employers for which occupational health advice is needed. It is therefore essential to find solutions to meet the needs of people at work in smaller businesses who either cannot access occupational health advice through reasons of finance or locality or are not motivated to do so. A snapshot of current types of provision is given in Appendix 8 . This excludes NHS providers who are covered in Appendix 9.
7.3 Employers who need help with the means of tackling difficult health risk problems or finding a suitable source of advice can, of course turn to HSE's Employment Medical Advisory Service (EMAS) (see Appendix 10) for assistance. In addition to HSE written guidance, HSE's field inspectors, medical and non-medical, and occupational hygienists and local authority enforcing officers give much practical advice to businesses of all kinds, particularly during workplace visits. They also generate and encourage sector specific guidance and exchanges of information through the industry Sector Groups. However each of Britain's larger cities are likely to boast more than 20,000 businesses, even in sectors where enforcement is by HSE alone, and there is a limit to which HSE and local authority enforcement resources can be stretched.
7.4 In focusing on SMEs the OHSWG has been careful not lose sight of the needs of larger companies. Some, in any case, behave like an agglomeration of smaller units with outposts unwilling to own occupational health (seen as a headquarters issue).
7.5 Ideally those companies that do provide occupational health support could be encouraged to offer help with occupational health issues to smaller colleagues. Although such arrangements, promoted by the HSE's Good Neighbour Scheme, the Workplace Health Advisory Team, mentoring projects and supply chain arrangements, do exist (see para. 23.5), they are rare. Until perceptions of occupational health are changed (see section 17) any downturn in the economy will put pressure on large companies' own arrangements and their ability to help sub-contractors and smaller colleagues with occupational health issues.
7.6 Traditional working patterns are changing and the OHSWG has also been mindful of the needs of people on rotating shifts, holding more than one part-time job, on short-term contracts and working at or from home. These issues and those of inequalities based on gender, ethnicity and disability etc. are explored further in Part 3.
8.1 The EU, DfEE and HSE define the size of enterprises as follows:
small = 50 or less employees
medium = 50 - 250 employees
large = 250 or more employees
*(In the UK, small enterprises include those run by the self -employed whereas in the EU the self-employed are counted separately)
8.2 Although there are representative bodies acting for small businesses in particular, e.g. the Federation of Small Business and the Forum for Private Business, SMEs are not a homogenous group and many see their identity in terms of the sector within which they operate rather than their size alone.
8.3 The following UK statistics1 give some indication of the contribution of SMEs to the economy:
The needs of SMEs for occupational health support(a) SMEs account for 99% of private sector businesses, 53.8% of industry turnover (excluding finance sector) and 56.8% of total employment;
(b) at the start of 1997, only 32,000 out of some 3.7 million enterprises could be categorised as medium or large;
(c) small businesses are the source of 45% of non public sector employment (including some 80% of construction sector employment)
(d) some 68% of businesses have no employees (incl. 29% of construction firms) and some further 21% have less than 5 employees.
8.4 In some ways it is arguable that SMEs needs are no different from their larger colleagues. Businesses of all sizes may need help with e.g. risk assessments, the level of health monitoring required, objective advice on employees with constitutional and often chronic health problems and healthy living issues. A recent literature search carried out for HSE2 showed that motivators for proactive management of health and safety differed little between large and small companies.
8.5 Nevertheless the characteristics of small firms do merit special consideration for the following reasons:
(a) although they often share a lack of motivation to manage health at work, SMEs are not a homogenous group - the needs of a firm of 20 employees will be very different from those of either a larger enterprise or a micro- business with three workers;
(b) the failure rate of small businesses in all sectors is high and they represent the majority in vulnerable sectors like livestock farming and catering, leading to significant potential for stress-related illness;
(c) employers and single managers often have to fulfil roles that in a larger company would form the responsibilities of a range of specialists, so they have little time to absorb guidance, recognise the existence of an occupational health problem or find out what to do about it ;
(d) limited time means that any health and safety resources are likely to be concentrated on prevention of accidents rather than illness that develops over a long period;
(e) trade union membership is lower in small companies and there are fewer safety representatives;
(f) as small businesses typically operate in fire-fighting mode, any health problems are dealt with in the same way and business vision is likely to be short, objective timescales are measured in weeks or months and the long term impact of sickness absence is not considered;
(g) the latent nature of occupational health problems, poor understanding of legislation on occupational health, the low profile of occupational health in management training, limited experience of human resource management amongst untrained managers, and accounting systems that render sickness costs invisible, all contribute to a lack of awareness of occupational health issues;
(h) many small businesses struggle to keep their heads above water, therefore solutions need to be cheap, convenient and particularly cost-effective.
8.6 SMEs tend to make no distinction between work-related and other sickness absence, the impact is the same. The respondents to the MORI interviews (see paragraph 2.4) indicated a general inability to associate illness with work practices. They did not consider that e.g. tiredness and stress caused by working practices might be the cause of absence or injury. Most were not able to put a figure on the costs of sickness absence while others believed that there were no costs involved. The employers in the sample tended to overlook the reduced productivity that could result from staff coming into work sick.
8.7 Although awareness of the detail of occupational health legislation was low, the majority of MORI respondents felt that because their companies were small and everyone talked to each other, there was no need for external help with controlling risks to employee health. Part of this may be explained by a reluctance to attract the attention of enforcing authorities and invite unwelcome recommendations.
Priority needs of SMEs8.8 There is a general consensus both within and outside the OHSWG that for SMEs the following needs should be addressed:
(a) the overriding need to educate employers and raise their awareness of :
(b) help with hazard identification, risk assessment and implementation of controls (e.g. ergonomic measures, process and system design) that is simple, focused and preferably sector specific;
(c) practical help with prevention of ill health through the use of tools such as monitoring of sickness absence, health surveillance, and systems that allow a balanced flow of work;
(d) help with human resource issues, good management skills and flexible working policies, and healthy living issues;
(e) advice on fitness for work issues, redeployment, rehabilitation and employing the disabled;
(f) help with setting up first aid, and where appropriate, other treatment services (e.g. stabilisation of injuries and acute ill health, helping disabled workers stay at work, preventive medicine and vaccinations for employees travelling abroad, helping to manage addictions);
(g) provision of a local one stop shop approach to business advice including occupational health and safety.
9.1 Although employees of larger companies are more likely to have access to
occupational health advice, lack of awareness of occupational health and suitable training remains a problem in some companies and economic pressures may lead to a reduction in e.g. health surveillance and the monitoring of control measures.
9.2 It has been mentioned that some large companies behave like agglomerations of small businesses. Others have the problem of large numbers of part-time peripatetic staff who rarely attend the company's base e.g. office cleaners, agency workers etc., some of whom may have no access to occupational health support.
10.1 Even where occupational health support is provided by employers, it is often viewed with suspicion by workers. A recent survey of union representatives by the Labour Research Department3 found that many still see occupational health services as a management tool, too concerned with sickness absence monitoring which could be used against staff. Other workers show the same lack of awareness of occupational health issues as employers and see support provided by doctors and nurses simply in terms of fitness examinations and getting treatment for injuries. Yet others will have high expectations of the company providing a safe and healthy working environment, cancer and other health screening opportunities and catering that includes healthy diet options.
10.2 Workers should be encouraged to take more responsibility for their own health at work. To do this they need to have confidence and understanding that:
(a) occupational ill health can be prevented and solutions to occupational health problems are available;
(b) people with disabilities and ill health problems can work provided that adjustments are made and work is designed to suit the individual;
(c) with advice and training, workers and their representatives can contribute significantly to the control and prevention of risks to health.
10.3 Priority needs for workers include:
(a) occupational health support that is seen to be objective and independent of undue employer/management influence, ethical and of the highest probity;
(b) support and advice concerned with risk prevention, disease prognosis and referral for treatment in a way that is not prejudicial to income or job security;
(c) where appropriate, support that is tailored to the needs of peripatetic workers and people who work at or from home (bearing in mind that children may also be at risk if e.g. process work or machining is carried out at home);
(d) training to allow safety representatives and other workers to become involved in risk prevention strategies; and
(e) the means of ensuring that their occupational health history is not 'lost' after job moves.
10.4 The need for occupational health support is not confined to employment. Workers who have retired or who are temporarily outside the labour market through unemployment, maternity leave etc. may still need access to advice, within local primary care arrangements, about ongoing work-related ill health. People with more than one job may need help with the synergistic effects of exposure. The increasing numbers of young people with asthma may need advice about occupations to avoid.
11.1 With the notable exception of asbestosis, and certain occupational cancers, occupational health issues are now less dominated by diseases and conditions that are directly linked to exposure to particular substances etc. at work. There is increasing recognition that much ill health at work is of a multifactorial nature e.g. stress-related illness and musculo-skeletal disorders, and that there are links between common illnesses and work e.g. higher incidence of certain heart conditions amongst shift workers, effects of work organisation on coronary heart disease and passive smoking. It is therefore important that occupational health support offers an integrated, holistic approach to health management that , (whilst giving priority to the prevention of work-related risks), will improve the quality of life for the working population within and outside working hours. This also has the merit of reducing sickness absence costs, enhancing productivity and competitiveness and, for individual workers, employability .
11.2 Careful management and occupational health support can not only help the ill or injured back to work but also, e.g. help employees who develop cancer, multiple sclerosis and other major illnesses, to continue working during treatment.
11.3 Some larger employers are taking part in national health campaigns aimed at promoting healthy living through exercise and diet choices and offering private medical insurance and wellness screening. A recent survey for the Institute of Directors4 found that, from a sample of 500 employers, 27% provided health advice and 41% health checks or screening. The workplace provides a captive audience and participants can be empowered to take charge of their own health with moral support from their colleagues. Employers have an important role in enabling workers to make healthy lifestyle choices e.g. by making sure that healthy dishes are available in staff restaurants. There are also benefits for the community at large e.g. through the reduction in smoking in public places and more commuters cycling and walking to work. However the promotion of healthy lifestyles at work does raise certain problems and ethical issues, including:
(a) how far should employers intervene in the freedom of workers not to take exercise, eat 'junk food' , smoke and drink etc. if they are not risking the health and safety of others?
(b) the time and resources that businesses can devote to occupational health are restricted and there is a danger that lifestyle campaigns and competitions etc. can divert attention and resources from employers' statutory obligations to prevent risks to health from work activities;
(c) interventions that focus primarily on the empowerment of individuals e.g. stress management techniques, can mask the management systems which are at the root of the condition;
(d) as discussed in the recent 'Acheson Report'5, campaigns e.g. against smoking have the least effect on the most disadvantaged people.
11.4 This argues for careful prioritisation of occupational health resources as discussed in paragraph 12.4 below.
12.1 Making occupational health support and advice accessible to everyone who needs it is not simply a matter of providing more resources and incentives. There is a general consensus amongst occupational health professionals, employers' associations, trade unions and intermediaries alike that improving access to occupational health support cannot be considered in isolation from the need to promote awareness of the need for such support. The fundamental issue is one of recognition that the prevention of work-related ill health should form an essential aspect to the running of any organisation. For that to happen, occupational health should become as embedded in our every day consciousness as e.g. road safety. Therefore the delivery mechanisms discussed later in this Part also address, to some degree, the raising of occupational health awareness, although there are wider issues involved here.
12.2 Heightened awareness, together with suitable incentives, should stimulate the use of occupational health support and lead to an improvement of the health of the adult population by:
(a) mitigating, reducing and ultimately preventing work-related ill-health so that work is fit for workers and workers are fit for work;
(b) ensuring that everyone including the disabled and those in need of rehabilitation etc. have the support necessary to realise their full working potential and;
(c) ensuring the positive effects of work can be maximised.
12.3 Occupational health support should empower employers to deal effectively with potential risks to health without lessening their responsibilities and help workers achieve greater control over risks in their working environment. It is therefore essential to ensure that there is sufficient occupational health support in a range of disciplines and specialisms to meet the varying needs of all enterprises. To meet these needs, it will be necessary to establish the kind of local partnerships discussed in Section 25.
12.4 Small businesses have the least resources for occupational health and it is probably unrealistic to expect them to embrace all aspects of occupational health support when some are barely on the road to accident prevention. The OHSWG believes that prevention of work-related ill health is the priority need. This argues for occupational health support for SMEs that focuses primarily on problems that:
which can be overcome by :
Healthy living issues should be targeted and relevant to the specific needs of the workplace concerned.
13.1 Health inequalities stem from a complex interaction, between low income, employment status (or lack of it), socio-economic class, education, standard of housing and other environmental factors. Neither prevention of work-related ill health nor workplace advice on healthy living can deliver all the solutions to health inequalities amongst the adult population. Even where there is occupational health support, people may not know how to make use of it. In the case of healthy living advice, targeting small businesses could be an inefficient use of resources as it is much harder to reach the same number of workers through small businesses than via large ones. In any case, focusing on healthy living issues tends to improve the health of the better off, possibly reflecting individuals' perceived ability or lack of it to take control of their life.
13.2 Nevertheless, there is much that can and should be done to tackle health inequalities through the workplace. The 1995 Labour Force Survey figures show that blue collar workers experience more injuries at work and work-related ill health than white collar workers. Manual workers, along with nurses are more likely to have left their jobs through work-related ill health than non-manual workers. Once an employee has left work through health problems it becomes increasingly more difficult to re-enter work. The Acheson Report has noted that, on the whole, the unemployed suffer more ill health than those in work.
13.3 The economic circumstances of people living in deprived areas, particularly ethnic minorities, young people, single mothers, and older men without skills or qualifications, may force them into low paid hazardous work which could reinforce some existing non work-related threats to health. Workers at the lower end of the labour market have been most affected by economic changes in terms of low paid , temporary and insecure employment, adding stressors to their lives. It is the lower socio-economic groups that are most likely to be exposed to the imbalances of demands and control at work that can lead to heart disease, musculoskeletal disorders, mental illness and sickness absence.
13.4 Other work-related inequalities in health include the following:
(a) shiftworkers are known to be at increased risk of ischaemic heart disease6 and their working hours may mean less access to e.g. occupational health support or even GP care (insecurity of employment may encourage acceptance of less safe conditions);
(b) working conditions in many female dominated occupations e.g. hairdressers, dry cleaners, sewing machine operators are more likely to cause gradual deterioration of health, dramatically visible only in the long term, therefore risks are considered insignificant7 and their job content is often characterised by high demands and low control, factors which can lead to stress;
(c) women may respond differently than men (on whose experience most occupational health research is based) to exposure to risk due to physical, metabolic, genetic or other differences8 but their problems are sometimes perceived as less serious than those of men (however gender differences are not well understood);
(d) ethnic minorities are more likely to be unemployed than the white population and have less choice about the work they do9 - they may also be isolated from occupational health advice through language barriers and cultural pressures;
e. the disabled are three times more likely to be unemployed than the non-disabled10, but more could be employed if companies had more advice about doing so.
13.5 Some of these issues can be tackled by raising employers' awareness of what constitutes a healthy workplace, together with good human resource management practice. Therefore one of HSC/E's current priorities is to work closely with the Minister for Public Health (MPH) on the Healthy Workplace setting of the Government's public health strategy for England. This involves HSE in working with DH to develop a national framework of workplace health which builds on existing initiatives and promotes good practice in relation to both the process and content of a workplace health programme. The three year strategy will be developed as a holistic, sustainable approach to workplace health to:
The primary target groups for the strategy will be the public sector, and SMEs including the very small businesses of less than 10 employees.
13.6 The strategy will address not only the activities associated with workplace health but also the process which an organisation must follow in order to make the changes necessary to support health and sustain activity. It will be
(a) launched with an initiative to tackle backpain followed by an initiative on mental well-being; and
(b) be supported by a description (shared by HSE/DoH other key stakeholders) of a healthy workplace, and a national framework of workplace health.
The framework will build on existing initiatives and promote good practice for establishing a workplace health programme.
The need for partnerships at local level
13.7 The healthy workplace strategy should help to meet the gap between local provision and need, and create synergy between the occupational and public health agendas. Central to the development of partnerships to promote health are Health Improvement Programmes and Health Action Zones.
13.8 Health Improvement Programmes (HImPs) are, in essence, local plans of action focusing on improving health, reducing health inequalities, and developing modern, fast and accessible NHS services of a uniformly high standard. The HImP process is action, not paperwork focused. It combines clear and far reaching objectives with firm commitments to action, measurable targets for improvement, and clear monitoring of progress. Each Health Authority concerned has responsibility to lead the development of the local HImP with the accent on the widest possible involvement from the outset. The local NHS, Local Authorities, patients, carers, employers and community groups all have a real opportunity to shape the HImP so that they feel ownership of its objectives and are committed to its implementation. The first HImPs have been prepared for the period from April 1999, and ultimately will cover a three year rolling programme with elements of the programme updated on an annual basis.
13.9 Health Action Zones (HAZs) were launched to target areas of high health inequality and aim to tackle health inequalities, reshape services better to meet local needs, and develop new approaches to partnerships between key public players. These will include the NHS, local authorities, community groups, and the voluntary and business sectors. The aim will be to develop and implement a health strategy by better-integrated arrangements for treatment and care to deliver measurable improvements in public health and in the outcomes and quality of treatment and care. More information on HAZs is given in Appendix 11
13.10 The often multifactorial causes of ill health at work and the effect of work on health also demand a co-ordinated response from local authorities, local health authorities, the NHS, trade unions, other local intermediaries and agencies like the Health Education Authority etc. that gives at least equal support to work-related and non work-related causation of ill health. It is therefore essential that occupational health support is linked strategically with HImPs and HAZs, and operationally with local welfare and healthcare services including Primary Care Groups (PCGs) (see also section 20 and Appendix 9) HImPs /HAZs may offer the opportunity to target workplaces with the greatest proportion of individuals in need. Establishing a flow of occupational health information between PCGs and HImPs would help in this process.
13.11 An example of a partnership in action is afforded by the work being carried out by the Sheffield Occupational Health Development Group (SOHDG), funded by HSE, to identify the occupational health needs of SMEs in the Sheffield area. The results of this work will help to inform the development by SOHDG of a comprehensive occupational health support service for businesses. This will help to inform HSE's wider work and, it is hoped, act as a template that others may be able to adapt for their own use.
13.12 Effective networks between the various organisations with an interest in health already exist in some localities; for others it will be a ground-breaking experience. It would help to get the process on a sound footing and make for a consistent approach, possibly to form the basis of future guidelines if research was commissioned into the best methods of working together.
Section 13 above discussed the ways in which occupational health support can underpin the removal of health inequalities. These and the delivery mechanisms for occupational health support suggested later in this Part will only be effective if more employers and workers are prepared to change their behaviour and make more use of competent advice. Sections 14 to 16 below discuss ways in which this might be brought about.
14.1 There are many within and outside the occupational health field who would argue that the only way of guaranteeing a change in behaviour on the part of employers would be the introduction of new legislation to make the provision of occupational health support mandatory. Supporters include large businesses, particularly those who provide in house support and no doubt wish to see a level playing field, some public and private sector providers, and trades unions. Equally there are many, including health and safety professionals, who believe that more and stricter legislation will have no effect on those who cannot keep up with existing requirements or who are determined not to comply with laws that are seen as a burden. Others favour an approach based on an approved code of practice.
14.2 The 1992 Regulations do require employers to appoint competent persons to help them with occupational health problems as well as safety. It is arguable therefore that all that is necessary is in place, the difference from the mandatory provisions envisaged by some is that the need for competent advice is based on risk assessment and the form that the advice takes is not stipulated, to allow for flexibility in sourceing that advice. But it is disappointing that even some health and safety/occupational health professionals perceive that occupational health is not covered by this requirement and that occupational health is somehow distinct from health and safety.
14.3 The introduction of new, more explicit legislation could be a powerful incentive. The fear of prosecution, and the moral impetus to comply with the law, which is a significant driver for 'responsible' companies would do much to raise the profile of occupational health as an integral part of health and safety. But with some 1.2 million businesses in the UK11 comprising more than one person, enforcement would be challenging and irresponsible employers may be tempted not to comply. People comply with the law if they perceive it to be sensible and well founded12 . Small businesses may feel that the cost of occupational health support will put them out of business which would not benefit the long term welfare of their employees. The MORI survey indicated some small businesses would not comply with a mandatory requirement. There may be difficulties if the only way businesses e.g. in a particular geographical area could achieve compliance was through purchasing support whilst those in other areas had access to free initiatives.
14.4 It is by no means clear that new legislation would serve the purpose of improving health. Even within the SME sector, occupational health needs are so divergent that they would be very difficult to legislate for and inappropriate use of occupational health support could be as damaging as no use. It would be difficult to build in sufficient flexibility to allow a truly multidisciplinary approach or to cover healthy living issues without affecting workers' freedom of choice. Where would responsibilities fall if there was no occupational health support locally available in the neighbourhood? How could the self-employed and micro businesses comply? Clearly a long lead in would be required whilst an infrastructure was developed to provide support to every business. Arguably, more is likely to be achieved by persuasion.
14.5 However, the TUC believes that it would benefit both workers and employers if the 1992 Regulations (see para 5.2) were amended to place a duty on employers to ensure their workforce have individual access to occupational health support from medical services to advice. One way to give concrete form to this proposal, as has been discussed by the TUC and Forum of Private Business, would be for employers to provide their workers with a statement of the hazards to which they might be exposed in the workplace. This could be taken by the worker to the employer's in-house /contracted-in independent occupational health service, or to the worker's GP (or practice nurse), or subsequently to a specialist to whom they have been referred. Employers could be required to generate such a statement as part of the risk assessment process and supply it to employees on a regular, (perhaps annual) basis or whenever the latter indicate an intention to consult their GP. In doing this, the TUC believe that employers might be held to have fulfilled a requirement to provide access to occupational health support. But the duty might be more effective if it required employers to ensure that there was adequate occupational health support available to their employees. This would effectively entail employers providing such support directly or through collective funding effected e.g. by an insurance system.
14. 6 The OHSWG has concluded that the introduction and objectives of far reaching legislation of this kind cannot be considered in isolation from wider strategic issues concerning occupational health which are beyond the remit and timetable of the Group. Such issues will need to be addressed by the long term strategy for occupational health currently being developed by the HSE.
15.1 A different approach to legislation would be the use of a mandatory self audit by employers of the health and safety performance of their organisation, into which healthy living issues could also be built, based e.g. on an annual return or questionnaire which would be accompanied by guidance on responsibilities and issues to be addressed. A self audit of this kind could be developed from written statements and written risk assessments. This would force employers to consider the adequacy of health and safety arrangements in all organisations and prompt management in larger ones to question their arrangements. On the base of a limited sample, indications are that this would be an acceptable way forward to many both in the small business sector and those in the occupational health field, with suggestions for an accompanying media campaign e.g. a 'Hector' figure as used for self assessed tax returns. It is interesting to note by way of precedent that, until recently, the Secretary of State had power to specify by Regulation classes of company required to include health, safety and welfare information in their director's reports. This power was first introduced by way of section 79 of HSWA which amended the Companies Act 1967. The provision was carried over into the Companies Act 1985. No Regulations were ever made and the relevant section was repealed in 1996.
15.2 Some trade associations and employers' organisations already produce their own checklists and self-assessment packages. It has been argued that these create a 'tick box /complete and comply mentality' and that they are of daunting size for hard-pressed SMEs. These criticisms may be justified but it should be possible, to design a return that is both focused and capable of testing respondents to show whether real assessment and action to implement controls has taken place.
15.3 The audit return, which should cover both health and safety, could include prevention, risk assessment, advice sought, worker involvement, rehabilitation and employment of the disabled and healthy living. The return would need to be supported by guidance notes on its completion, including ways of telephoning returns and sending them by electronic means.
15.4 Mandatory self assessment or auditing would need to be introduced by new legislation, probably by amendment to the 1992 Regulations. Voluntary self- assessment is another possibility, but this is more likely to result in returns limited to those from self-selected, more responsible employers, unless a particularly juicy carrot can be dangled. In this context, it is perhaps of interest that a Work Injury Reduction Programme is currently being trialled in Alberta, Canada. Employers who have voluntarily opted to join the scheme are required to undergo an annual audit of their management systems The audit focuses on corporate leadership, operations, human resources, facilities and services, administration, health and safety information and promotion. The organisation's performance is scored out of a possible 2000 points to provide an index of progress. Employers are required to take action on the results of this audit and the report recommendations in order to qualify for financial (tax) incentives. The potential exists for large companies to receive incentives as high as $2 million.13
15.5 The major issue surrounding the self assessment approach is how to get the returns checked. If they are not seen to be checked, the initiative would have no credibility and the enforcing authorities would miss out on a lot of valuable information. If HSE were to undertake the task, significant extra resources would be required to do so. Other possibilities would be accrediting bodies such as TECs, Business Links, Chambers of Commerce to do so and provide information from the returns to the enforcing authorities. OHSWG therefore recommends that the self audit option merits further exploration.
16.1 Experience has shown that legislation is unlikely to be wholly effective in changing behaviour unless it is accompanied by another element of persuasion. This may take several forms; the obvious one of business incentives, raising awareness to a level where the need to create a health working environment becomes second nature and easing the path to compliance through readily accessible occupational health resources delivered in a way that fulfils business, particularly SME needs .
Costs and benefits16.2 One of the most effective incentives for individual organisations would be convincing evidence that the costs of ill health interventions would be outweighed by the benefits. Unfortunately just as the costs of sickness absence are hidden in company accounting systems, information on the costs to employers is hard to come by. There is little recognition e.g. of the effects on productivity of employees operating below par over a period of time. Unlike accidents, much of the direct and therefore visible costs of ill health are borne primarily by the sufferers, secondly by society and only marginally by employers unless there is a costly legal settlement (see figure 1 below).
The 1995 Self-Reported Work-Related Illness survey showed that in that year, around 2 million people suffered from a work -related illness, disability or other physical problem caused or made worse by work. As a result, some 19.5 million working days (equivalent to 0.71 days off per worker) were lost in sickness absence that year. In this survey, those who reported a work-related illness were asked for permission to obtain information from the doctor who treated the illness. Such information, where obtained, usually supported the respondent's belief that the condition was work related. However a significant proportion of the employers involved did not accept that the illness or condition was caused or worsened by work.
16.3 Such global figures seem to be too remote to impact on small businesses who fail to make the link between work and illness or do not perceive they have a sickness problem. More pertinent may be health and safety projects like that named after Sir Frank Davies, chair of HSC until the end of September 1999, and carried out by South West Water15. This health and safety compliance programme, set up to be applicable to the water industry generally, concluded inter alia that the representative cost to that industry of each case of Work Related Ill Health amounted to £8,650 (calculated by working with Personnel Offices, occupational health experts and sickness absence information from line managers and including claims and settlements). Case studies focusing on work related upper limb disorders and hand arm vibration syndrome each demonstrate that 10 year costs of the compliance programme will easily be outstripped by 10 year savings in ill health costs. Further information of this kind, preferably in the form of case studies, should be sought for use in campaigns and guidance on the benefits of preventive occupational health strategies.
16.4 Employers would have an incentive to seek advice from competent persons if employers' insurers could be charged for the treatment of work related injuries, ill health and rehabilitation, leading to higher premiums. A possible precedent is provided by the proposed Road Traffic NHS Charges Bill aimed at empowering NHS Trusts to recoup from insurance companies the costs of treating the victims of road traffic accidents. At first sight it might appear that something similar could be introduced to charge employers' insurers for the treatment of injuries received at work. However recouping the cost of treating illness would be more problematic. Most occupational ill health, leaving aside the acute effects of poisoning and the results of some exposures to biological agents, take several years to develop. Thus cases of illness may be difficult to attribute to a particular period of employment if the employee concerned has moved from job to job with similar hazards. Conditions with multifactorial causes will present similar difficulties. In addition, the organisation where the employee was exposed to hazardous agents may have gone out of business by the time that symptoms become apparent. It could also make employers reluctant to employ workers with a pre-existing health condition and encourage them to put resources into first aid and treatment facilities at the expense of preventive activities. .
16.5 In view of these complex considerations the OHSWG was unable to reach a consensus on recommending an exploration of the possibility of charging employers' insurers for treatment of work-related injury and illness. Similar arguments could be advanced concerning increased national insurance contributions for employers whose employees experience injury or ill health at work. Employers Liability Insurance
16.6 Companies are already liable to attract higher insurance premiums if they have a poor health and safety record. Annual premiums are based on a percentage of the wages bill, the type of industry or service and the associated risks, and the claims experience of the organisation insured. Can insurers offer lower premiums, therefore, to those who do perform well or fulfil a minimum standard of prevention? Generally speaking and with certain notable exceptions, it is would seem to be only the large companies and correspondingly large scale initiatives for which insurance companies find it worthwhile to offer reductions. Within the context of current arrangements, especially the state administered benefits system, insurers' most valuable role is likely to be one of undertaking surveys and providing information, advice and management services.
Industrial injury benefit16.7 The OHSWG understands that the Government is examining the scope for modernisation of the Industrial Injuries scheme with the aim of providing better protection from the risks and consequences of occupational disablement for the workforce of the future. This may prove relevant to the consideration of incentives to seek occupational health support and to raising employer awareness of occupational health issues.
Tax relief16.8 It is frequently suggested that SMEs in particular should be able to earn tax relief for buying in occupational health advice or training workers in occupational health support. However the Inland Revenue advise that such items are already tax deductable provided it furthers business interests and is not purely altruistic in intent. As with every other business expense, the tax deduction amounts to a contribution rather than reimbursement. A bigger tax incentive, perhaps linked to self audit as trialled in Canada (see para. 15.4) would demonstrate Government commitment to the cost effectiveness of occupational health provision but initial costs are likely to be prohibitive in the shorter term. For the moment, SMEs would seem to need more information on tax deductions for occupational health support.
16.9 Another approach would be to raise a levy on all employers, refundable where effective health and safety training is provided for employees, on the former training board model of the 1960s and '70s. This could provide an initial incentive for organisations large and small which do not currently regard training as an investment. However the proportion of small firms was much lower when the industry training boards were in operation. This time, the 'winners' i.e. the larger firms with higher staff turnover would be much fewer in number. The system could penalise small firms with low staff turnover where training needs might be much more limited.
16.10 Business levies need not be linked to training. A broader per capita levy on employers, could be raised to pay for the provision of occupational health support. A business levy could, for instance be used to support a NHS occupational health service . However in that example, a levy would not be easy to sell to businesses which did not use NHS support. It might also disadvantage low cost providers of occupational health support such as academic institutions.
16.11 In the 1970s, Sweden established a Work Environment Fund (WEF) which is essentially a levy on employers augmented by Government. This was aimed e.g. at improving health and safety at work through research, improved education and training in health and safety for both employers and employees, and addressing psychosocial issues at work. In addition the 1980s saw the introduction of a surtax on employers who could apply for reimbursement on the basis of improvements in e.g. workplace design. Neither source of funding was directed at or contributed to the support of occupational health services. The WEF had considerable impact in raising levels of awareness, and development of methodologies but none on resources for occupational health support. Political changes and questions of efficacy mean that the surtax is no longer raised and the WEF is in gradual decline.
16.12 The issue of business levies raises complex problems relating to the maintenance of flexibility of occupational support, what employers could obtain in return for levy outlay and the position of employers who already pay for support, which it was impracticable for the OHSWG to explore fully.
Reduction in business rate16.13 The OHSWG feels strongly that an important financial incentive could be provided by a reduction in business rate for businesses that bought in occupational health support. The advantage of this would be a clear gain in return for investment. It is understood that this issue is being explored in at least one local authority. Admittedly there would be a number of complex issues to be resolved, not least of which would be :
Nevertheless, a pilot study would be worthwhile to see whether such problems are surmountable.
16.14 Awards that enhance the image of an organisation have traditionally been a prime motivator for proactive management in any field. Many companies have taken part in initiatives involving both occupational health and safety and general health, which lead to some form of recognition which either reflects well on company image, products and services or is otherwise valuable in securing contracts. But there are drawbacks, e.g.
On the plus side, they:
Some employers are moving towards evaluation of the impact of such awards in their workplaces.
16.15 The Health Education Authority's (HEA's) workplace health award scheme offers a quality standard and a framework for achievement that is more demanding than those of other health and safety awards. There are three levels of attainment in recognition of different starting points e.g. the award has provided a framework to allow organisations who have never tackled workplace health before, to make a start. The intention is to help get occupational health embedded in company planning systems and at the same time provide some guidance on how to go about it. The scheme operates in a similar way to Investors in People in that participants have to produce a portfolio of evidence for assessment. However some means are needed to make the assessment process less expensive for both parties. The training of local and local health authorities' staff as assessors is currently being piloted at eight sites. As it provides a framework within which organisations can address a number of occupational health management issues and generate case studies, the HEA approach could form a useful model for the recognition of a healthy workplace.
Extending the Investors in People Standard16.16 It is often suggested that one way of obtaining more employer commitment to occupational health would be to extend the Investors in People Standard (IiP) to include health and safety performance criteria. This is an attractive proposition in that IiP forms a sustainable 'bottom up' approach to improved management practice. However extending the Standard in the way suggested could undermine the IiP 's focus on training. This leaves the following possibilities which could be considered:
17.1 Some limited success in encouraging SMEs in the belief that straightforward measures to control risks to health are effective and easy to implement has been achieved by the Good Health is Good Business campaign. This is a major campaign to help employers manage workplace risks and point them in the direction of further help and advice, emphasising that measures to control and prevent exposure to health risks at work need not be costly or difficult. The campaign has been undertaken in three phases each targeting two or three specific types of work related ill health. So far it has focused on manual handling, occupational carcinogens, noise, solvents, hand arm vibration, dermatitis and respiratory sensitisation. A fourth phase on the theme of "making it happen" is planned for launch in autumn 1999 will build on the work done in the earlier phases.
17.2 Despite this, occupational health is still seen by many employers as the province of health care, welfare and human resources staff or services rather than a business management issue. Consequently there is little investment in training and resources for occupational health. Workers too may not perceive the full preventive potential of occupational health support or know how to take control of their own health. This situation is unlikely to change until occupational health achieves proper recognition as a management issue and lifelong learning is accompanied by lifelong health education as peoples' working environments change. To achieve this aim, several things must happen:
(a) the prevailing low level of competence throughout some management chains as well as within SMEs with little or no management structure needs to be addressed
(b) the business culture will need to be changed:
(c) workers need to be trained in health and safety but training is more effective if it builds on existing knowledge, preferably gained in school and further education;
(d) safety representatives are already actively involved with community and schoolwork that raises the profile of health and safety; more use could be made of safety representatives in this way;
(e) The profile of occupational health would be raised significantly if the health needs assessment undertaken within HImPs included occupational health (see recommendation 4 and paras 13. 7 to 13.8 ).
17.3 There are a number of ways in which employers, managers, safety representatives and others can themselves achieve a greater level of competence through training and self development. New vocational units , designed by the Employment National Training Organisation with help from HSE, have been introduced to enable people without specialist knowledge or competence in health and safety to gain a wider knowledge of requirements. Although the units do not make up a complete NVQ or SVQ they have been accredited as part of the NVQ/SVQ framework and successful candidates will be certificated. In addition, the National General Certificate (NGC) issued by the National Examining Board for Occupational Safety and Health (NEBOSH) is aimed at managers, supervisors and employee representatives. It requires 80 -100 hours' study and candidates are assessed by written examination and practical assessment. There are currently some 42, 029 holders of the NGC but it is not known how many of these have direct health and safety responsibilities. The number is low in comparison with the number of businesses in current DTI statistics (see para. 14.3). There are also some 2,977 holders of the NEBOSH National Diploma, introduced in 1988 for health and safety practitioners. A new two part NEBOSH Diploma was introduced in 1997; holders of Part 1 Diplomas may be admitted to the Institute of Occupational Safety and Health (IOSH)16 grade of Technical Safety Practitioner and holders of Part 2 satisfy the academic requirements for admission as a full Corporate Member of IOSH. Help for managers and employers who need to review their own competence is discussed in paragraph 19.3.
17.4 There also other routes to competence. Those described in para. 17.4 for instance would not suit everyone. Trade Unions already provide some training in health and safety for their members and should be encouraged to expand this.
18.1 The following sections are based on certain OHSWG conclusions as follows:
(a) occupational health support can take various forms - there will not always be a need for health care resources - a multidisciplinary approach will often be needed and many small businesses needs may be met by someone able to solve e.g.. basic engineering or ergonomic problems.
(b) the needs of different employers, workers and others are each so diverse that no single solution/delivery mechanism will work for everyone;
(c) the infrastructure necessary for a comprehensive national occupational health service does not exist and such a service might prove too inflexible to meet the needs of e.g. employers who need occupational health support of a non-medical nature, isolated communities etc.;
(d) there is no need to start from a completely clean sheet, many of the building blocks are there but they need to be used in more innovative ways;
(e) solutions should help employers but not shift their responsibility for the protection of worker health.
18.2 There are basically three levels at which employers may need occupational health support and advice (see the model at figure 2). Some problems may only need input at level one whilst others may require help at all three levels. In particular:
19.1 HSE has already produced a large body of written guidance. Smaller firms say they want hazard or sector specific guidance on key health issues. HSE has responded with simple guidance on key health issues and these have been heavily promoted. The Good Health is Good Business campaign, which, as noted in para.17.1, has had some success in helping small businesses to manage health risks in simple, cost effective ways is now approaching its fourth phase. It is disconcerting therefore that some in the small business and occupational health fields still perceive a lack of such advice for SMEs. This may reflect discomfort with the goal setting approach of health and safety legislation and guidance, which may not be helpful to small businesses and their employees.
19.2 Ways of making guidance more attractive could include:
(a) encouraging Industry Advisory Committees to review needs for sector specific guidance and involving trade associations and other fora in producing it;
(b) sharpening current guidance, making it simpler to follow with less acronyms and less emphasis on goal setting, and more focused on the practical needs of business;
(c) making guidance more freely available, through free literature available at a variety of public places and on the Internet and HSE's website;
(d) providing interactive advice on HSE's website;
(e) exploring what lessons can be learned from other successful campaigns involving e.g. avoiding drink when driving;
(f) identifying successful formats for guidance, website entries etc.
19.3 The OHSWG has concluded that there is one area in particular where new guidance is necessary in order to help employers to fulfil their obligation to appoint competent persons under the 1992 Regs. Employers, particularly those with small businesses may find it difficult to know:
(a) whether they themselves are competent to act or "competent persons" appointed from the work force are competent in relation to managing and protecting the health of the workers and recognise the limits of their experience and knowledge;
(b) when external support is needed , what the indicators are, what kind of support is needed, how to find such support, what experience and qualifications to look for (including the pitfalls of seeking advice from GPs, nurses and other advisers without appropriate levels of occupational health expertise) and how to get the best from the support.
Therefore, practical guidance is needed that employers can refer to as required. It would also help to stimulate demand for providers of occupational support who are appropriately qualified. This would also help to make clear that the competent advice requirement applies to occupational health problems as well as safety.
19.4 HSE's field operational staff, including the Employment Medical Advisory Service (EMAS) (see Appendix 10), and local authority environmental health officers etc. do provide much face to face and 'hands on practical' advice during visits to workplaces. EMAS is well respected for its role and expertise in providing advice on occupational health problems of all kinds to employers and others, and is an important resource for employees and their families for whom there are few other sources of advice. But current EMAS investigative and inspection commitments mean that it could not deliver a comprehensive support service or, for instance provide a dedicated telephone helpline without a change of strategy accompanied by a significant augmentation of resources. (Telephone helplines are discussed further at para. 23.2.)
19.5 Messages from the MORI survey and other sources suggest that many small firms are reluctant to call on HSE for advice, fearful that they will attract enforcement activity or that someone will dictate to them ways of carrying out their work. Some felt that the advisory and enforcement aspects of HSE's work should be separated.
19.6 So far, this Report has considered indirect advice channelled through various media. The following Sections consider the delivery of advice on a more personal basis. Bearing in mind Ministers' concern to address health inequalities, the first of these sections considers the contribution that primary care can make to the health of workers particularly those employed in very small businesses, and ex-workers, for whom other delivery solutions are less likely to be viable. It is logical to follow this wi with a consideration of the role of the NHS. Finally we report on private delivery of occupational health care to complete the medical aspects and move on to non-medical solutions, which for many SMEs will prove as least as important as medical ones.
20.1 Whilst there is a wide range of external 'experts' and problem solvers, within and outside occupational health specialisms, to whom employers can turn to for advice, a significant proportion of the working population have no other source of health advice but their GP. Yet training for GP practice contains little or no occupational health content and many GPs are contracted to employers to provide occupational health support. This section discusses ways in which primary care could contribute to an improved level of occupational health support, particularly for workers, in conjunction with Primary Care Groups (PCGs), city Occupational Health Projects, HImPs and secondary care provided by NHS Trusts.
Contract services offered by primary care staff20.2 There are four levels of GP involvement in occupational health as follows:
(i) every GP, under their terms of service has to provide certification before they can practise but their training does not usually cover occupational health;
(ii) some GPs act as 'Appointed Doctors' carrying out medical surveillance as required under the Control of Substances Hazardous to Health Regs. 1994 (appointment is by HSE at the discretion of senior medical inspectors based on the doctors' experience in occupational medicine and work place factors);
(iii) GPs who provide occupational health support to employers on a commercial basis - such providers should preferably have at least a Diploma in Occupational Medicine and some workplace hazards merit more but many such GPs do not hold occupational health qualifications;
(iv) GPs who have obtained a higher specialist qualification in occupational medicine.
20.3 There are major issues arising from the GPs and nurses without specialist occupational health expertise who have contracted with employers to provide occupational health services as in 20.2iii above but who are not fully aware of the kind of services they should be delivering. This can mean that the organisation does not get effective or suitable advice and interventions are of a minimal and reactive nature. There may be problems, too, surrounding workers' perceptions of the impartiality or otherwise of the service and a potential conflict of interest if a GP provides an occupational health service to the employer of a patient. Guidance on the selection of competent advice, as envisaged in Section 19 above should encourage the demand for qualified practitioners. The OHSWG is aware of moves by the General Medical Council to ensure that doctors do not practise within fields where they have insufficient expertise.
Training and qualifications in occupational medicine20.4 There are three levels of qualification in occupational medicine offered by the Faculty of Occupational Medicine (FOM). The Diploma in Occupational Medicine (DOccMed) offers a minimum qualification for any doctor, including GPs, providing occupational health advice, although doctors providing a service to hazardous industries or heading a team of providers should ideally have (and in some cases will need) Associateship (AFOM) or Membership (MFOM). The AFOM is a mid-training qualification, whilst the MFOM is a career specialist qualification. Specialist training in occupational medicine is prescribed by the Faculty of Occupational Medicine and conforms to requirements of the European Specialist Medical Qualifications Order 1995. The route to entry on to the Specialist Register of the General Medical Council involves four years training in an approved post and attainment of the AFOM and MFOM.
20.5 In 1994, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) set new standards for the education of occupational health nursing. These have led to the introduction of new programmes for occupational health nursing at not less than first degree level, leading to the recordable qualification of Specialist Practitioner (Occupational Health Nursing). There is nothing to prevent state enrolled nurses working as occupational health nurses but only those qualifications which meet the new specialist practitioner can be recorded on the Professional Register maintained by the UKCC. Recordable qualifications can be obtained by distance learning and companies etc. who employ nurses without occupational health qualifications should consider giving them help, encouragement and opportunity to undertake distance learning. This would also provide an opportunity for practice nurses to acquire competence in occupational health.
Primary care as an essential provider of occupational heath support20.6 There are many workers and others for whom primary care will remain the only viable option for advice on work-related ill health e.g. the self-employed, employees of very small businesses, people who work at home, mobile workers like cleaners, voluntary workers, part-timers with more than one job, people in isolated rural communities, the retired and the unemployed. Continually changing patterns of employment will ensure that this analysis will remain valid for the foreseeable future. It is therefore essential that GPs are able to recognise the possible links between their patients' health, the work they do and what action to take with reference to the employer
20.7 There are a number of other ways in which GPs and practice nurses can increase their knowledge of occupational health for instance:
(a) GPs who are not intending to undertake contract work but who need training to help patients with work-related symptoms will benefit from taking up the FOM/Royal College of General Practitioners Distance Learning Package, funded by HSE, DoH, and DSS, which should become available this year;
(b) following evaluation of the GP distance learning package, a similar one could be developed for practice nurses who could undertake some of the workload in giving information on occupational health to patients and passing on local information to health authorities;
(c) Membership of the Society of Occupational Medicine (which is open to GPs via sponsorship of existing members) offers opportunities for professional refreshment in the occupational field through site visits, academic meetings and networking with other doctors;
(d) specialist (nurse) practitioners (practice nursing) on the UKCC Professional Register can also undertake the Short (35 day modular) Programme in Occupational Health Nursing; this is difficult at present as students either have to be working in occupational health or have access to an Occupational Health Department for the duration of the course but PCGs working in partnership with NHS Trusts may be able to establish some arrangements to allow practice nurses access to the latter's occupational health support units;
(e) greater encouragement of networking opportunities between practice nurses and nurses in NHS occupational health units, who usually have occupational health qualifications, could result in an exchange of information and experience;
(f) HSE is also contemplating guidance for primary care staff and patients to replace the booklet 'Your patients and their work' and leaflet 'What your doctor needs to know'.
20.8 Other primary care staff such as health visitors and physiotherapists, if suitably trained, could prove a means of reaching people working at or from home, the disabled and retired etc., although opinion varies as to the feasibility of this.
20.9 The accessible nature of primary care argues for it to provide a large proportion of occupational health care services, particularly for the categories of workers referred to in para. 20.4. Counter arguments could be raised on the basis of GP shortages and the numerous burdens already placed on GP surgeries. However, given that many patients will present with work-related symptoms or symptoms that could be worsened by work if not properly managed, a clearly focused approach to occupational health of primary care patients should save time and resources in the longer term.
20.10 The best means of ensuring that primary care can meet the occupational health needs of patients would seem to be the promotion of occupational health care within the Primary Care Groups (PCGs) that will come into operation on 1 April this year (see para.13 of Appendix 9). One of the main functions of PCGs will be to improve the health of the community they serve and address health inequalities. A health needs assessment will be an essential pre-requisite of this task and will form part of the HImP. Occupational health needs should be fed into the HImP via the Health Authority and also direct to the PCG. A significant relationship in bringing this about will be that between occupational health and local authority, personnel, including those in public health departments, NHS occupational health units, environmental health officers and HSE/EMAS. PCGs be in a strong position to promote aspects of the National Service Frameworks like mental health and the development of strategies for those at risk.
20.11 In order that PCGs can address occupational health needs as fed into HImPs, PCGs should be encouraged to engage someone with occupational health and safety expertise to champion health at work within the Group. A variety of people could fulfil this role e.g. a health and safety adviser with qualifications from the National Examining Board for Occupational Safety and Health, or an occupational health nurse. PCGs should encourage the designation of GPs and nurses in larger practices as occupational health 'specialists' rather as some GPs already 'specialise' in areas like well women and children's ailments. In the case of smaller practices, it may be possible to appoint roving 'specialist ' GPs or occupational health nurses. In some areas it might be possible to establish primary care occupational health centres although the Group was unable to reach a consensus on this.
20.12 The accountability of PCGs to Health Authorities via HImPs and the NHS will make them useful channels through which to feedback information on local information on the incidence of work-related ill health as well as successes which could inform local occupational health strategy. Linked to the PCG structure is the work being taken forward by the NHS Executive to ensure that primary care staff have access themselves to occupational health support. This should act as a psychological driver for GPs to also consider the occupational aspects of their patients' health.
20.13 Heavily burdened GP practices, even where there are doctors or nurses with occupational health knowledge or experience, are unlikely to remain continuously focused on the occupational health needs of their patients. At surgery level patients will need advice on the links between ill health and exposure to risks at work, non-medical advice on how to change or influence their working environment and negotiate change with their employer, rehabilitation and entitlement to benefit and compensation. In eight large cities or conurbations including Sheffield, Leeds, Liverpool and Lothian, there are city Occupational Health Projects (OHPs) which offer a way of meeting these needs as well as collecting data on local occupational health trends. Occupational health advisers interview patients in GP waiting rooms and make four main kinds of interventions:
In addition GPs are able to refer the patient to the OHP although levels of referral are relatively low when the OHP Adviser is not based in the surgery. However the OHPs are not a homogenous group and working methods vary; some focus entirely on workers' needs whilst others work with very small businesses as well. Some like Sheffield have established homeworking projects and ethnic minority programmes involving e.g. information campaigns in minority languages directed particularly at the self-employed and family businesses. The Liverpool OHP has developed a strategy for improving access to advice for employers workers, health care providers and other providers, targeting companies with fewer than 20 employees. The source of funding for OHPs varies from project to project and most operate from one year to the next with no secure assurance of continued funding. The OHSWG considers that secure funding should be provided to allow the OHP system to be evaluated, and if appropriate, expanded, especially in areas where health inequalities are greatest. Firstly however, the methodologies adopted by the OHPs and the prevention elements of their work need to be evaluated, and some overarching consistency of approach adopted. A research proposal to evaluate OHP methodologies and outcomes has been put together by the OHPs with the assistance of the Institute of Occupational Health.
21.1 The level of occupational health provision within the NHS is described in
(a) provide a consistent standard of effective occupational health support for NHS employees;
(b) provide sufficient occupational health support for employers where, for reasons of geography, nature of employment, other sources of advice are thin on the ground;
(c) be capable of providing affordable support for small businesses without prejudicing the support provided for NHS staff;
(d) provide secondary level support, information and specialist consultation/ referral for primary care services;
(e) improve links between NHS occupational health units and the diagnostic and treatment services for occupational diseases and allow for co-ordination of services with primary care provision;
(f) progress working age adult rehabilitation.
21.2 This level of provision is unlikely to be achieved without additional funding together with more trained personnel in a variety of disciplines but savings will be made in the long run through reduction in occupational illness. Additional funding may be attracted if occupational health treatment per se was widely refundable through private health care insurance. This may involve the recognition of occupational medicine as a NHS specialty with patient referral facilities.
21.3 The problem is not 'simply' one of providing enough trained specialists. A consultant dermatologist, faced with a patient who has work-related dermatitis may have little knowledge of causal relationships with substances work. This is a similar problem to the one of GPs who have insufficient awareness of occupational health to make a link between ill health and work activities. At present there is little training for student doctors or nurses who do not wish to pursue occupational health as a specialty but who nevertheless need a grounding in risk control and other occupational health issues. It is therefore important that more training in occupational health and risk control is given to student doctors, and nurses at an appropriate stage in the curricula.