Why occupational health should be universally accessibleBMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1291 (Published 06 June 2023) Cite this as: BMJ 2023;381:p1291
- Lara Shemtob, academic clinical fellow in general practice and occupational health physician1,
- Kaveh Asanati, professor in occupational health and consultant in occupational medicine1,
- Shriti Pattani, president of the Society of Occupational Medicine and consultant in occupational medicine2
Employers, workers, and the healthcare profession can all benefit from occupational health, but only if it’s accessible. More people than ever in the UK are becoming economically inactive, often because of ill health.1 But what is occupational health? How does it fit into the healthcare landscape? And can it help us tackle the current issues with labour force supply?
Occupational health is all about the relation between work and health. This link goes both ways. We know that work is generally good for our health,2 but it can also cause and exacerbate ill health. Though we may have learnt at medical school about rare occupational diseases such as pigeon fancier’s lung, the most common occupational illness is work related mental ill health.3 In the fourth quarter of 2022, 2.5 million people of working age4 were economically inactive owing to long term ill health or disability, more than 20% of whom said that they wanted to return to work.5
Part of the role of occupational health specialists is to risk assess and manage the effect of work on the health of a workforce at an organisational level. Another aspect is assessing and supporting people who are working while experiencing ill health. Very often the incentives to promote good occupational health align: a healthy workforce is good for employees as well as the wider organisation, economy, and healthcare services.
Not a level playing field
Access to occupational health in the UK is not a level playing field. It was excluded from what the NHS provided when the service was first set up, and there have been several unsuccessful attempts to rectify this since. What this means in practice is that access to occupational health is not universal in the UK, as access varies between employers. We don’t have a good understanding of who has access6 to occupational health and who doesn’t, but the most generous estimates suggest that only around 50% of workers have some form of access.6 People working in the public sector and large private sector companies are most likely to have access to occupational health. Workers at the bottom of the socioeconomic ladder, such as those in insecure employment or on “zero hour” contracts, are the least likely to have access. Working conditions, including access to occupational health, feed into the social determinants of health.
Occupational health professionals bring together knowledge of medicine and the workplace. The teams are multidisciplinary: nurses can work alongside doctors as occupational health advisers, and teams may include physiotherapists and psychological practitioners. They work with employers to help people with ill health make adjustments to their work to allow them to keep working where possible.
Under the right working conditions, work is beneficial to our health. Disability status can change, and being in work has been associated with people changing status from disabled to non-disabled. Among disabled people who are in work one year, 91.2% are still in work the year after—and 43.4% of these are no longer classed as being disabled.7 On the other hand, working through a period of ill health can be challenging for everyone involved, and this can give rise to conflicts of interest between worker and employer and can involve managing clinical risk. This is where occupational health comes in.
Workers who can’t get access to occupational health through their employer rely on their treating clinicians to advise them on health and work. Most of the time this happens through “fit” notes. These are most often authorised by GPs or, since July 2022, other members of the primary care team.8 Most patients think of these as a binary “sick” note. But the fit note replaced the sick note over 10 years ago, introducing a “may be fit for work” section. The purpose of this was to open discussions between patient and clinician about adaptations or adjustments that could help keep people doing some work during a period of ill health. Data on the use of the fit note9 suggest that the “may be fit for work” section is used less than 10% of the time. Barriers to using this in a GP setting10 include restricted appointment times, limited occupational health expertise, and patient expectations.
Evidence based initiatives
The government has acknowledged the gap11 in the healthcare landscape regarding occupational health, and it has set out some initiatives to help small and medium sized enterprises (SMEs) offer access to occupational health. These initiatives do not go far enough. More change is needed to make sure that people working throughout the economy have access to appropriate work and health support. The Office for Budget Responsibility3 has estimated that only 10 000 more people will be in employment in five years’ time as a result of the government’s plans, which compares with half a million4 people with long term ill health who want to return to work.
Financial resources12 remain the biggest barrier to SMEs implementing occupational health for their workers. Another issue is expert support to help these employers navigate the market and decide which initiatives to invest in.12 The global corporate wellness market was worth $53bn (£42.8bn; €49.7bn) in 2022,13 but it isn’t always evidence based. Making sure that SMEs’ and taxpayers’ money is spent on evidence based initiatives that will help employee health, retention, and productivity is essential. SMEs include a large proportion of employers in the social care sector,14 where there are significant workforce challenges with a knock-on effect on the NHS.
Alongside more government investment and support for employers, integrated care systems have the potential to form the basis of joined-up care between the Department for Work and Pensions and the Department of Health and Social Care. Meanwhile, occupational health as a specialty needs to grow to meet demand.15
Competing interests: None declared.
Provenance and peer review: Not commissioned, not externally peer reviewed.