Occupational health should be part of the NHSBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2334 (Published 23 May 2017) Cite this as: BMJ 2017;357:j2334
- Correspondence to: I Torrance
Occupational health was not included in the NHS when it was formed in 1948, and this has not changed despite successive reports arguing that work is important for overall wellbeing.12 The growing shortage of occupational health doctors adds urgency to calls for the specialty to be integrated fully within the NHS.
In 1948, funding for occupational health and the development of the specialty were driven principally by health and safety legislation. Workplaces were more physically hazardous than they are now. Many workers developed diseases caused by exposure to agents such as asbestos and coal dust, prompting targeted, specialist health surveillance of those at risk. The duty to manage work place hazards, including provision of health surveillance, rested then, as now, with the employer.
In the past 70 years work has been made safer and the prevalence of occupational illnesses caused by exposure to specific workplace hazards has fallen. At the same time, emphasis has shifted from prevention of illness to overall wellbeing. There is stronger focus on disability and the adjustments required to enable work, coupled with a better understanding about the adverse health effects of prolonged absence from work.
This agenda was accelerated last year by publication of a government green paper on work health and disability.3 The consultation, which closed in February, asked for views on the current service, “Fit for Work.” This is telephone based but enables a few people to have a face-to-face meeting with an adviser, although not a specialist occupational health physician. The green paper recognises the importance of more comprehensive provision of occupational health to people of working age and proposes exploring service models that integrate occupational health into both primary and secondary care.
As far back as 2008 another government report had been prompted by a situation where markers of health such as longevity had consistently improved but many more people were claiming incapacity benefit because they were too sick to work.45 A subsequent report in 2011, Health at Work, an independent review of sickness absence, emphasised the importance of early access to rehabilitation services to prevent long term incapacity and absence from work.6 Both reports raise concern about detachment of occupational health from mainstream healthcare.
The “fit note” soon followed,7 enabling general practitioners to tell employers what tasks people are fit to do, rather than simply signing them off sick. However, this may not be straightforward for people with complex needs or multimorbidity.
Occupational health specialists have particular skills in evaluating physical and mental ill health together in the context of work. They have the ear of both employer and employee and the capability to empower both parties to find effective ways of achieving the mutually beneficial outcome of meaningful work.
Who should pay for occupational health services? Many large businesses, including the NHS, see a business benefit from providing occupational health for their staff, usually in the context of well developed health and safety protocols and policies to manage attendance. However, employees in small and medium sized enterprises have patchy access to occupational health, and unemployed people have no access.
Ill health among working people costs the UK economy £100bn (€118bn; $130bn) a year, while economic inactivity costs the treasury around £50bn a year, including £19bn in welfare benefit payments.3 So the government also has a powerful economic incentive to pay for broader provision of occupational health services. The most obvious route would be to integrate occupational health into NHS care systems.
Full integration would require recruitment of many more occupational health doctors along with associated specialist nurses. But there is an ongoing crisis in both staffing and training.
A recent report from an all party parliamentary group highlights that 64% of occupational health specialists are now older than 50 and also notes a collapse in the number of trainees.8 In 2015, there were just 74 trainees across the whole of the UK.8 Only about 13 doctors achieve accreditation in occupational health each year, according to the Faculty of Occupational Medicine’s latest figures. The specialty is at risk of losing the critical mass of accredited doctors required to maintain future training capability.
The 2016 green paper brings timely political attention to a problem that is important to individual health, public health, employers, and the UK economy. It makes proposals key to the future of occupational health, and it is important these are translated quickly into action.
The nature of work has changed substantially since 1948. Integration of the clinical specialty of occupational health into the NHS is long overdue. If action is not taken soon, it could take a generation to train enough specialists to make integration a realistic possibility. The UK economy, workforce, and healthcare system cannot afford to wait.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare both authors are occupational health specialists working in the private sector.
Provenance and peer review: Not commissioned; externally peer reviewed.