TUC Evidence to the Dame Carol Black review of the health of Britain's working age population

Introduction

The TUC welcomes the opportunity to contribute to Dame Carol Black's review of the health of the working age population. The TUC contribution to Dame Carol Black's review will concentrate primarily on the role of prevention, rehabilitation, and the provision of occupational health services within the work context, however the TUC also shares the governments desire to support as many people as possible to get off incapacity benefit and back into work.

Currently 7.5% of the working age population are claiming incapacity benefits because of sickness or disability. Every year another 600,000 new people flow onto incapacity benefit.

175 million days of sick leave are taken every year at a cost to the economy of around £13billion. Of these, the Government states that 36 million days are lost because of ill health related directly to a person's employment.

The Health and Safety Executive estimate that 2.2 million people are suffering from an illness they believe was caused or made worse by their current or past work. Of these 646,000 were new cases within the last 12 months. In addition there were 274,000 reportable injuries in the past year. Overall these led to an average of 1.5 lost days for every worker in the UK.

Of the 2.2 million cases of self-reported occupational ill health, over three quarters were musculoskeletal disorders or mild to moderate mental health problems caused by work-related stress.

There is still a tendency to view occupational diseases and illness as being a thing of the past, mainly related to industries such as mining and heavy engineering. The reality is very different. Despite huge advancements in technology and changes in the labour market the International Journal of Occupational and Environmental Health has claimed 'never in history has there been so much occupational disease as exists in the world today'. Much of this is because of the emerging problems of new jobs and new work methods.

A report in 'Hazards' magazine in November 2005 highlighted the failure of official statistics to recognise many of the occupational diseases that are now leading to long-term illness. This report suggests that even the estimates of 30million days lost a year are a considerable underestimation as many people are unaware that their illness is work-related. This is particularly the case with many musculoskeletal disorders, occupational asthma, hearing loss, and stress related illnesses.

In addition to injuries and illnesses that are directly work-related, there is a considerable synergy between occupational and non-occupational causes. In practice, in most cases of illnesses that are common within the population in general, individual attribution is impossible. This is particularly the case with musculoskeletal disorders, mild and moderate mental health issues and sensitivity illnesses, where both work and domestic exposure may be involved. In addition, many illnesses caused by lifestyle, environmental, or domestic factors can be made worse by work-related exposures. This means that the actual level of work-related illness and injury is almost certainly considerably underestimated.

The traditional view of health and safety has also led to the health of women being either overlooked or minimised as an issue. Men have more 'accidents' but women suffer more occupational ill-health. This was highlighted in a recent report produced by the European Agency for Safety and Health 'Gender Issues in Safety and Health at Work'. We believe that the review should specifically address gender issues. We need a clearer picture on gender difference and the different impacts on men and women at work and also address the apparent neglect of women's occupational health and the failure of the public health services to address women as workers. We hope the review will look at the research undertaken by Karen Messing on the treatment of gender in occupational health and by Lesley Doyal on gender, health and health care.

We do know that a lot of sickness absence, particularly work-related sickness absence, is easily preventable and the main focus of any government strategy must be on prevention. However support must also be given to those who are already ill or injured, or who are on long-term benefits. The government has already made some in-roads into this through 'Pathways to Work'. In addition they have published 'In work, better off: next steps to full employment', and are seeking to reform the benefits system. They have also announced proposals to develop the availability of CBT to certain long-term claimants.

Social security benefits and health

There is a certain degree of confusion in public debate between a number of different issues that relate to the rights and responsibilities of sick and disabled people. These include the claim that engaging in paid work can be good for one's health; the claim that there are large numbers of disabled people whose preferred option would be paid employment; the argument that disabled people who are capable of paid employment should be required to look for it and to accept job offers; the claim that there are a significant number of people claiming benefits who are not really sick/disabled.

The TUC does not dispute claims that well managed work in an environment where hazards are controlled (paid or unpaid) can be good for individuals' health, in comparison with inactivity. We do not object to using the benefits system to underline this message. But it is also true that there are times when work is not a reasonable expectation. Most people can understand that workers with infectious diseases should not be expected to return to employment, but it is also true that working with a debilitating condition or returning to work when one is no longer infectious but still not fully recovered can lead to long-term performance problems. Working when suffering from pain or fatigue can cause or exacerbate chronic conditions, forcing workers into less productive jobs or out of employment altogether. No-one should be forced to work when this would cause them pain, excessive fatigue, loss of mental acuity or exacerbate these problems. Most workers lack financial independence and occupational sick pay - supported by the benefit system - should protect them from feeling that they do not have the option of sick leave.

The Government often emphasises the fact that there are a million disabled people who say they want jobs. A million people is a large group, but it is worth bearing in mind that there are two million working age disabled people who do not want paid work, and the TUC would strongly oppose any attempt to require them to be available for employment. Some of these disabled people may have concluded that their condition rules out paid work.

An even higher proportion of the incapacity benefit claimants who do not want jobs may well have decided that their experience of discrimination and exclusion indicates that, in practice, they are unlikely to get jobs. This is not unreasonable; in 2005 the Chartered Institute for Personnel and Development found that, when recruiting, 33.1% of CIPD members excluded people with a history of long-term sickness or incapacity, even though such a policy would almost certainly leave employers very exposed should a disappointed applicant use the Disability Discrimination Act against them.

It is simply not the case that large numbers of benefit claimants are fraudulent. We have already addressed the myth of the 'sick note culture'. Far from having trivial or mild conditions, researchers have found that, when the impairments of claimants of incapacity benefits were ranked on a severity scale ranging from zero to ten, over half had a severity score of five or higher. The survey also found that 64 percent of the participants said their condition had been affecting their ability to do paid work for more than five years, and 90 percent expected their conditions to last for at least another year. There is a very low level of Incapacity Benefit fraud; as the official benefit review of Incapacity Benefit noted:

'Due to the small number of confirmed fraud cases found during the review, it is not possible to produce a robust central estimate of the total annual value of benefit overpaid due to fraud for short-term Incapacity Benefit and long-term Incapacity Benefit. However, an indicative upper limit has been produced. It is estimated that the amount of overpayment is less than £19m, i.e. less than 0.3% of all expenditure on cases in receipt of these rates of IB. Similarly, it is estimated that the percentage of all IBST(H) and IBLT cases that are fraudulent is less than 0.5%.'

The TUC is also concerned that aspects of the benefits system, including the qualifying period for many benefits, often acts as a disincentive to return to work, or forces people to return to work before they should. This also applies to the absence of, or extremely short time set for over run of benefits on return, which leaves people without any income for up to several months. We hope that these issues will be considered by the government in their review of benefits.

TUC Recommendations:

• That policies to encourage paid work should also acknowledge the need for short, long-term or permanent absence with support from occupational or state benefits.
• Benefit rules should not require disabled people to look for paid jobs until discrimination against them is ended in practice as well as principle.
• Ministers and officials should take the lead in arguing that fraud by sick and disabled people is uncommon.

Role of Prevention

The TUC believes that the first priority for the government in dealing with the current epidemic of occupational ill health must be prevention. In recent years the Health and Safety Executive and local authorities have moved away from simply seeing their role as dealing with occupational safety and have instead become involved in issues around occupational health. The HSE have been at the forefront of dealing with the prevention of stress related illnesses and their guidance is among the best internationally. The HSE 'Fit 3' programme has also begun to pay dividends in influencing levels of musculoskeletal disorders.

Unfortunately this work is under threat by the significant under funding of the Health and Safety Executive and local authorities, who also have an important enforcement role. Since 1997, the UK workforce has increased by around 9%. In that time, the Health and Safety Executive workforce has shrunk from over 4,000 to a current strength of a little under 3,500. Also the number of premises the HSE inspect has gone up by around 20% in the past 5 years alone.

This has already had a significant effect on the service the HSE provides. In the past 4 years the number of inspections fell by 25% while the number of prosecutions fell by 49%. It is hardly surprising that last year saw the highest number of workplace fatalities in 5 years.

If more resources were to be allocated to prevention then clearly there would be significant gains for the economy, employers, and of course workers themselves. By preventing people becoming ill or injured through work the economy could save billions of pounds through sickness absence, benefits, medical costs and compensation. Yet the amount that the government gives to the HSE is less than a third the amount that the state pays out in compensation through the industrial injuries scheme.

In addition to the role played by the HSE and local authorities one of the other most effective tools in preventing injury and ill health is the role of trade unions. There is a wealth of evidence that safety representatives, safety committees, and trade unions, are one of the major factors in reducing both injuries and ill health. Research has shown that those employers who had trade union health and safety committees had half the injury rate of those employers who managed safety without unions or joint arrangements. Further studies in 1998 and 2004 have confirmed the general conclusion that a union presence significantly reduces workplace injury rates. But it is not only injuries that trade unions help reduce. It is also ill health.

In their publication, 'The Union Effect' the TUC has published a range of case studies showing that where employers and unions work together they can make a significant reduction in the injury or illness rate within an employer. The HSE have also produced a number of studies which are on their website.

Unfortunately, the TUC believes that for many in government, and within the occupational health profession, workplace health provision is something that is done for workers, rather than with workers. The task of making real in roads into the epidemic of workplace ill health can only be achieved in partnership. That means a partnership with employers, providers, insurers, government, and the workers and their representatives.

The TUC believes that involving union safety representatives in the process is likely to have a major impact in the awareness and provision of occupational health in the workplace.

The TUC is currently working with the HSE to provide training for at least 10,000 safety representatives every year in occupational health issues. We have also produced a number of resources on the issue. However much more needs to be done to involve safety representatives in the workforce.

Were the government and HSC to increase the ability of safety representatives to be effective through increasing their legal powers, and if they were to encourage employers to work more closely with unions, that itself could make a significant difference to the number of people becoming injured or ill as a result of the working environment.

In recent decades there has been a significant shift towards smaller employment units. That means that the traditional model of one safety representative covering a specific workplace or part of a workplace is often no longer practical and other models need to be developed such as the ability of safety representatives to operate across a number of employers or a number of workplaces.

In addition the low number of inspectors, and workplace inspections, mean that more use should be made of the existing 200,000 safety representatives who could provide invaluable assistance to the enforcing organisations. The TUC has long called for safety representatives to be given the ability to issue notices to employers that they are breaking health and safety law to give them the opportunity of rectifying a breach prior to the enforcing body having to get involved. This system has operated successfully within Australia and would be ideally suited for the UK.

We also believe that it is important that the safety representatives' role within the occupational health field is better recognised and they be designated 'health and safety representatives', rather than 'safety representatives'.

There is also far more that should be done to ensure that employers take health and safety seriously. The penalties available against those who are prosecuted are, by the Governments own admission, far too low, and the lack of a specific duty on directors means that there is little incentive on directors to even consider the health of their workforce when making decisions.

Equally, there is no requirement on employers to even report their safety performance, let alone audit it. In their report on improving access to occupational health support, the Occupational Health Advisory Committee recommended that the government should look at the use of a mandatory self audit by employers on the health and safety performance of their organisation, into which healthy-living issues could also be built. The TUC believes believe 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. This approach would be particularly useful for SMEs.

TUC Recommendations:

• That greater resources be allocated to the HSE and local authorities to enforce health and safety regulation.
• That the regulations relating to safety representatives be changed to make them more able to operate in the modern workforce and to allow them to complement and support the work of the inspectorate.
• That safety representatives should become 'health and safety representatives'
• That there should be a legal requirement on employers to conduct an annual self audit of the health and safety performance of their organisation.

Sickness absence

The management of sickness absence within the UK is, to say the least, patchy. Many employers still believe that Britain actually has a 'sickie culture'. The reality is very different. The average number of sick days lost has fallen consistently over the past 10 years and numerous surveys have found that far more people come into work when ill than do not come into work when actually well by faking illness.

Much has also been made of the difference between absence rates in the public and private sector. It is claimed that this shows that the private sector deals with the issue better and that a lot of absence in the public sector is therefore fake. However differences relate almost exclusively to long-term sickness absence and simply reflect the differences in payments made to workers while off sick between the sectors rather than any real difference in how the sectors deal with the issue.

Unfortunately many managers still see the management of sickness absence as being about trying to get an employee to return to work as soon as possible. This means sickness absence policies are often simply another method of employer control that do nothing to tackle work-related causes of ill health and injury and can increase workplace bullying through the way they are implemented by managers. Often punitive policies are used against those who are ill, or absence targets and scoring systems are used which ignore valid causes of sickness and individual circumstances.

A positive sickness absence policy can help to pinpoint work-related issues such as health and safety risks, stress and bullying. It can tackle those organisational issues that can give rise to absence and provide support to promote staff attendance through positive interventions, which can have a significant effect on reducing absence. It must be linked to return to work policies and rehabilitation policies. There is considerable evidence that where an employer has attempted to manage sickness absence and return to work issues with trade unions or safety representatives they have made considerable inroads.

The Health and Safety Executive have produced clear and practical advice on the management of sickness absence and the TUC would commend this as being the template which employers should use. The production of further guidance, such as that being considered by NICE simply confuses the issue. Instead the Government should be encouraging the adoption by employers of the HSE guidance.

Linked to the management of sickness absence and return to work is the role of GPs. There is considerable pressure for a change in the way GPs are involved in sickness absence from employers who want to maximise attendance and also from GPs themselves who feel that it is not their role to write sick notes. The piloting of alternatives is already underway. Some of these pilots, such as proposals to introduce electronic sicknotes may prove to be useful, but in addition there is considerable interest in company doctors and other occupational health professionals becoming the first contact for sick employees.

This move is not a practical one for most employees as very few have access to any kind of occupational physician and for many workers, even if there is provision, it often simply amounts to an occupational health nurse at a company head office which can be many miles away. Nurses are also not in a position to diagnose and treat conditions in the same way as doctors. The TUC has expressed concern that any shift to company doctor issued sick notes would only work if staff believed that there was 'unbiased and independent advice on treatment'. That is not the case. Many workers see their employer's doctors as having closer links to the human resources department than the workforce. On the other hand GPs are seen as an independent health advocate from outside the workplace whose sole concern is the health and wellbeing of the employee rather than industrial relations issues.

It is likely that, for the vast majority of workers, the GP will remain the first point of contact. Unfortunately many GPs will have no idea what job a person does or who they work for. The TUC would recommend that GPs should have to record the occupation and the postcode of the employer for every patient who is in work. As well as helping GPs relate a problem to a persons work, it would also make surveillance easier.

In addition, most GPs, at present have little training or awareness of occupational medical issues. It is only recently that there has been any mention of occupational medicine within undergraduate medical training and even now it is woefully inadequate. In addition there is currently no occupational medicine element within the training of most GP registrars, although that is likely to change in the future. The TUC would like to see more training of GPs in occupational health issues, more GPs within an interest in occupational medicine and also the introduction of occupational medicine into secondary care.

The TUC believes that there is a role for both GPs and occupational health physicians and other professionals within the management of sickness absence. In January 2003, a survey by Leeds Occupational Health Advisory Service found GP referrals to surgery-based occupational health advisers led to 55% of patients saying they made fewer visits to their GP, 30% saying it helped them return to work earlier, and over 30% saying it led to 'positive action' to improve health and safety at work.

The preference for the TUC is a mix of interventions in occupational health involving GPs, specialist GPs within each area and also the use of occupational health advisers working alongside GPs within surgeries. However replacing GPs as the first point of contact for most workers would be completely inappropriate. Not only do most workers have no access to an occupational physician, but they have no idea whether their illness or injury is occupational or not. Other models, such as setting up telephone lines for people to discuss their illness with an on duty nurse are usually viewed as an attempt by employers to get people to return to work as soon as possible rather than to seriously support those who are ill.

Unfortunately, at the other extreme, the TUC believes that the current 'sick note' system has led to the position whereby employers often abdicate any responsibility for an individual when they are off sick seeing it as simply a matter between the individual and their GP. This often means that workers have no contact with their employer while signed off sick beyond simply putting in a new sick note at regular intervals. This obviously has major implications for access to rehabilitation and these are dealt with later in this response. In addition it has led to the development of a culture whereby a worker is considered either completely unable to work, or completely fit to work. The reality is that for many workers there will be a period whereby they may feel able to return to work, but not fulfil their full duties. Many employers refuse to allow a worker back until such time as they are 'signed back on' by their GP. This is often because of fear of compensation claims if the person becomes injured again. In addition a worker who does return to work part time can often find that their benefits are withdrawn. The removal of the Reduced Earnings Allowance made this position worse.

In reality many workers would choose to come back on a gradual basis either on reduced hours, or a reduced workload, following a long period of absence. The TUC believes that this should be encouraged. Unfortunately it would also be open to abuse by employers. The employers may attempt to force a worker to return to work prior to them feeling confident to do so. Any moves for an early return to work on a reduced basis should always be initiated by the employee. In addition there is danger that where a worker returns to a work environment which was responsible for their injury or illness in the first place, then this could lead to a relapse. This is particularly the case with MSDs and psychosocial disorders.

There is also some confusion over the health benefits or otherwise, to the employee, of returning to work early. Guidelines on the management of back pain are quite clear that, in most cases, some activity can play a major part in rehabilitation. That has been interpreted by some as meaning that it is in the employee's best interest to return to work as soon as possible. In addition this policy has been applied to other MSDs by some employers. In actual fact there is little evidence that a return to work, as opposed to moderate physical activity, has a positive role in assisting recovery of any MSD, including lower back pain. An additional factor is that if a person is asked to return to work in an environment that may have led to, or made worse, an MSD then this could clearly either make a relapse more likely or delay recovery.

TUC Recommendations:

• GPs should record the occupation and employer of all patients in employment
• All GPs should have basic training in occupational medicine
• Occupational health specialists should be available through GP surgeries
• There should be specialist GPs in every area.
• Certificates of Sickness should remain to be issued only by doctors
• There should be changes to the benefits system to ensure that people who return to work gradually are not penalised

The relationship between health and work

There has, in recent years, been some discussion on the relationship between physical causes of illness and psychosocial ones. Work-related MSDs may, to a certain extent, be divided into those that occur as a result of a specific incident at work, such as a manual handling injury, and those which occur slowly over time and become chronic, although some MSDs fall in the middle. There is some evidence that many long-term chronic MSDs which develop over time, as opposed to those which are caused by an immediate injury, are not only a result of physical activity or a lack of good ergonomics but are related to the general working environment, including workplace organisation, culture, overwork, and management techniques.

A number of studies have confirmed that modern management methods are often responsible for the development of permanent, dehabilitating health problems and that the general work environment can be a major factor in both health and productivity.

Much has been made of the mantra that 'work is good for you'. The reality is that is not the case. While it is true that, for most people, being actively engaged is less likely to lead to serious long-term illnesses than unemployment and inactivity, being in work is, at best, less harmful that not being in work and even then only when it is properly organised, risks are properly managed, and staff are engaged in the work process.

The reality for all too many workers is that, rather than work being good for them, work in actual fact has made them physically or psychologically ill. Looking back we now know the long-term damage to the health of those who worked in mining, shipbuilding, asbestos industries, heavy engineering and stone working. However that does not mean that modern workplaces are, in the long term, necessarily safer. It may just be that we do not yet realise the dangers facing those who work in call centres, electronics factories, IT, etc. The risks from potential hazards such as EMF, nanotechnology, and simply modern working methods, may take many years to be fully understood.

To seriously reduce the levels of long-term sickness absence there first has to be an understanding of what 'good work' actually is. There then has to be a framework to ensure that those employers who do not operate to that standard are taken to task for damaging the long-term health of their employees. That requires a completely different approach to our understanding of workplace risk, and also the enforcement of health and safety regulations.

The TUC also believes that there is a role for rewarding good practice as well as penalising bad practice. We believe that those employers who take positive action and provide a safer working environment, should be rewarded through reduced insurance premiums. This may require the development of certifiable standards which employers would have to meet to be fully effective, but simpler models based on simple indicators like risk assessments and injury rates could be introduced much earlier. A system has been developed in Demark for use with the state insurance scheme and this has the support of both employers and trade unions.

In addition those employers who provide quality occupational heath provision and access to rehabilitation should not be penalised through the tax system as at present. We believe the government should revise the current tax system on occupational health and rehabilitation and even consider tax breaks for employers who meet a certain standard. Mandatory self-assessment or auditing could again be linked to incentives and disincentives and the TUC would recommend that this approach be considered.

TUC recommendations

• That the government fund the HSE to develop standards in those aspects of a working environment that promote health and those that are likely to damage health.
• That the insurance industry should do more to reward good practice
• That the government seek to reward employers who provide good occupational health support and rehabilitation

Lifestyle issues

There is a growing interest in using the workplace to promote solutions to 'lifestyle issues' such as obesity, smoking, drug and alcohol abuse. In some cases there is a link to health concerns and the working environment. These links include both sedentary work and long hours with obesity, and the links between stress and the use of tobacco, recreational drugs and alcohol.

The TUC believes that, where possible, the organisation of work should promote positive health through avoiding working arrangements which mean a person is inactive for long periods of time, or that a person is exposed to adverse levels of stress. Work-life balance policies are also an important contribution towards encouraging a healthier lifestyle.

In addition an employer can assist in the promotion of good health through a range of initiatives including providing access to healthy food, subsidising gym membership or encouraging exercise classes on the premises. Other successful initiatives have included subsidising nicotine replacement therapy, and access to counselling for those with a drug or alcohol problem. The promotion of cycling to work through providing secure bike-parking facilities, or of running through the provision of showers have also proved popular.

These initiatives are not however an alternative to ensuring that any workplace factors that may lead to addictive behaviour or other risks to health are removed. Lunchtime yoga classes are not a substitute for reducing stress in the workplace. Access to fresh fruit will not help employees who cannot even take a lunch break, nor will gym access be of use to those who work late every evening.

Often initiatives like these are introduced in a paternalistic, patronising way. If the employer is going to be involved in lifestyle issues then they should do it in partnership with the staff and their unions rather than on behalf of the staff. The TUC is aware of a number of instances where attempt to introduce 'healthy eating options' while at the same time removing traditional fare has led to considerable resistance from staff who do not take kindly to their employer telling them what they can and cannot eat. Instead such initiatives should involve consultation with the staff and have an element of choice rather than compulsion.

The TUC also has considerable concerns over attempts by employers to introduce moral elements to lifestyle issues. Drug and alcohol issues, for instance, are a concern when they affect the performance of a person in the workplace or put at risk the safety of workers or the public. Good employers will also wish to assist any employees who have an addition problem that is affecting them or their work. However that is a very different matter from the employer seeking to prevent drug or alcohol use outside the office if it has no bearing on the persons work.

Likewise there is a difference between an employer positively attempting to introduce choices and working methods that will help those people who chose to seek to control their weight, and an employer who sees it as their duty to make sure that anyone with an above-average BMI loses weight through forcing them to change their eating habits by creating a working environment where over-weight people feel stigmatised.

The workplace can, like any other environment, be a useful place to encourage people to make healthy choices, but it must be done in a non-judgemental way that creates the opportunities for people to make healthier choices should they so chose to rather than force them to adopt a particular lifestyle that has no bearing on their employment.

TUC Recommendations:

• While the workplace can be a useful place to promote positive health issues it must be done with the workforce and their union.
• The biggest lifestyle gains can be made through reducing stress, long hours and introducing policies that promote 'work-life balance'
• Employers must avoid getting involved in moral issues

Occupational Health Provision

At present it is estimated that less than 20% of workers are covered by any kind of basic occupational health support and only 3% provide comprehensive support. Even those employers who do have an occupational health service often seen as a glorified first aid service aimed at patching up the wounded and getting them back to work as soon as possible.

However good occupational health services can improve the quality of work, help assess, reduce and remove risks and ensure suitable jobs and adaptations for ill or injured workers, or workers with disabilities.

A good occupational health service will identify what can cause or contribute to ill health in the workplace, determine the action required to prevent people being made ill by work, introduce suitable control measures to prevent ill health, ensure people with health conditions or who have a disability or impairment, are not unreasonably prevented from working, ensuring people at work are fit to perform the required tasks through adaptations etc, providing health surveillance, reviewing records and promoting research, providing health education and counselling, supporting sick or injured workers.

The TUC has always contended that the UK government is failing to meet its minimum legal duty under the European Framework Directive, which requires all workers to have access to preventative occupational health services. There is a clear case for a legal requirement on all employers to provide such a service. Following action by the HSE, an employment tribunal recently ruled that a local authority was in breach of the Management of Health and Safety at Work Regulations by not providing an occupational health service for its employees.

Although the TUC believes that in-house provision is the best model for large employers, this may be inappropriate for some smaller ones and we would welcome the expansion of NHS Plus. NHS Plus was set up to provide occupational health for SMEs and unfortunately its effectiveness has been patchy. Due to a lack of resources and the way that NHS budgeting works, it really became more of a re-branding exercise for the pre-existing NHS occupational health provision, and has effectively acted more as an in-house NHS occupational health provider, than an external provider. It has also been suggested that staff within the NHS often feel that there is a lack of consultation and involvement

The TUC believes that NHS Plus has, were it to be properly resourced, immense potential to become a significant provider of occupational health services to small and medium sized employers. We believe its expertise would also be of use to many large employers.

However it will only be effective if there are major structural changes within the way the NHS operates and is funded, and also if there are greater incentives for employers to use an occupational health service, or ideally, it were to be underpinned by a statutory requirement on employers.

Another model of occupational health provision is local partnerships. An example of this is the Sheffield Occupational Health Development Group, which was funded by the HSE to develop the occupational health needs of SMEs in the Sheffield area. The results of this work helped develop an occupational health support service for businesses in the area, which is seen, by many, as an example of very good practice.

The TUC is concerned that the existence of the Employment Medical Advisory Service is also under threat. This service has dropped from 120 staff in the early 90s (half doctors and half nurses) to the equivalent of 7 full time doctors working as medical inspectors and 25 nursing staff working as occupational health inspectors. The TUC believes that proper resourcing for EMAS is necessary to drive forward occupational health in Great Britain and provide leadership to the system. A fully restored advisory service, such as EMAS, could be effective in providing incentives to employers to make occupational health provision and will be able to provide the necessary advice to employers, as parliament originally intended, when it was set up under the Health and Safety at Work Act.

The fourth report of the Select Committee on Work and Pensions specifically drew attention to reduced funding for EMAS and expressed the view that this had considerably reduced the capacity of the HSE to provide advice on occupational health issues.

TUC Recommendations:

• All employers should have a statutory duty to provide an occupational health service.
• That the work of NHS plus be developed and extended
• That local partnerships on occupational health be encouraged
• That EMAS be properly funded and its role increased and developed

Rehabilitation

The TUC believes that access to rehabilitation is vital. Clearly rehabilitation can only work if it flows from a wider occupational health provision. However there are some aspects of rehabilitation which do require it to be dealt with separately.

The TUC has raised the importance of rehabilitation with the government many times in recent years. It held 3 conferences on rehabilitation in 2000 and, in 2002 produced a discussion paper jointly with the ABI. It has followed that up with policy papers on rehabilitation and retention.

Britain is certainly lagging behind many other countries when it comes to rehabilitation. Within Scandinavia 50% of people return to work after a major injury. In the USA it is roughly a third. In the UK the figure is 1 in 6.

Currently access to rehabilitation primarily focuses on serious injuries. However there is some evidence that rehabilitation can be extremely effective in relation to both MSDs and also mild to moderate health conditions caused by stress. Between them these two groups of conditions make up over 70% of work-related sickness absence. They are also the major cause of long-term sickness absence, whether or not work-related.

Unfortunately uptake of rehabilitation is extremely limited. There is no legal requirement on an employer to even consider rehabilitation following an injury or illness.

However even if an employer wishes to provide access to rehabilitation, there are a lot of barriers in the way. The first is simply how to access rehabilitation services. In the absence of a national framework for providing rehabilitation services, the first port of call for most workers is still their GP. The majority of employers are content simply to allow the GP to deal with the condition rather than instigate any other intervention.

There is also a lack of knowledge on the part of employers (and many others) of what is effective, for what condition and when. We therefore welcome the current DWP initiated review which is aimed at getting this information.

Vocational rehabilitation is an industry where, in some areas, there is lack of consensus on issues around competency and professionalism. While there are some areas where levels of competency are well understood, such as physiotherapy, this is not universal across all disciplines.

Sadly, while everyone agrees that rehabilitation is important, making progress is a different matter. Often access to rehabilitation is dependent on the employers' insurers and therefore it is reliant on both a claim for compensation being lodged against the employer and also liability agreed. Unfortunately only around one in ten workers injured or made ill through work make any claim, and often this is many months after the incident.

In addition half of all compensation claims are lodged, not against the employer, but with the state Industrial Injuries Benefit Scheme, again there is no link with rehabilitation. As most claims under the accident provisions are made at least 90 days after the injury, and often several years after, the scheme would have to be changed to encourage early claims before a condition has become chronic and disabling.

For employers the main issue apart from where to go to access services and when, is who pays up front for rehabilitation - them, the insurer, or the state? They are also concerned about the tax position.

There is nevertheless a consensus that access to rehabilitation can, in most cases, be cost effective. There is also a consensus that the case manager system is the most effective way of providing and managing rehabilitation.

The TUC believes that there is an urgent need for a national framework of rehabilitation, underpinned by national standards. We would also wish to see greater provision of rehabilitation through the NHS, preferably using NHS Plus, as well as a statutory right to access to rehabilitation.

TUC Recommendations

• There should be a national framework for rehabilitation, underpinned by national standards
• There should be a statutory right to rehabilitation.

Occupational health and occupational diseases - research

Much of our knowledge of occupational illness is based on information from health surveillance obtained from doctors working for large companies or organisations, who had access to the health records of employees over a long period of time. This allowed the causal relationship between various diseases and risk factors to be more quickly understood, although in some cases, like asbestos, the employers did their utmost to stop the evidence becoming known.

In recent decades there has been a shift away from large employers to smaller ones, less people remain within the same workplace, or even industry, for all of their working lives, and the number of doctors working for a single employer is also much lower. This means that we have far less research evidence available on the causes of modern occupational diseases.

In addition the number of people involved in academic research has also fallen. While there are some centres of excellence they are few and far between. Funding is difficult to come by and the Research Assessment Exercise for academic institutions is a disincentive for research into occupational health and medicine as fewer points are given for occupational medicine than other comparable disciplines such as environmental medicine.

The research budget of organisations like Industrial Injuries Advisory Council is far too small to be more than of limited use. The TUC believes that funding of research into occupational health and medicine should be a priority for the government. If we are to understand and combat the diseases of the 21^st century, we need to know what we are facing as early as possible to ensure that preventative action is taken.

The legal requirement on employers to provide health surveillance only applies to certain jobs and industries where the risk is known. It therefore means that information on new areas of work or emerging illnesses are far less likely to be identified at an early stage. This contrasts with the much wider surveillance programmes in some northern European countries.

A lack of both surveillance, and epidemiological analysis based on that surveillance, means that we could well have a repeat of the asbestos tragedy of the latter part of the 20^th century.

TUC Recommendations:

• Funding available for research into occupational health needs to be considerably increased
• The recognition given to occupational health research through the Research Assessment Exercise needs to be improved
• The requirement on employers to provide health surveillance should be strengthened

Report (7,400 words) issued 23 Nov 2007