Up to a third of UK social class differences in health was probably caused by work 50 years ago. Since then, many hazardous jobs have been exported but new types of unhealthy work have emerged.
Work can be bad for health but so is unemployment. The most disadvantaged suffer unemployment in recessions and poor-quality work during economic growth. Work in a safe and supportive environment benefits health.
Chronic illness and disability often prevent obtaining such work, or lead to its loss. People with impairments should be employed for their abilities. Punitive ‘welfare to work’ policies damage health, cause stress and diminish self-respect.
Profit-driven economic activity can damage health through pollution, environmental harm, unhealthy products and unhealthy lifestyles.
Comprehensive occupational health services provide biological monitoring, employment rehabilitation, workplace clinical services and health promotion. They support workplace health and safety systems, identifying hazards, assessing risk, preventing occupational disease and supportively managing disability and sickness. They should also work with trade union health and safety representatives in the workplace.
About a third of the workforce had a comprehensive occupational health service in the 1980s, a third had a partial service and a third had no service.
Most of the workforce today have no direct access to occupational health services.
Occupational health services in the UK have never been statutory, but mostly employer-provided services. There have been campaigns to incorporate occupational health into the NHS, but by 1980 this was seen as medicalising the issue.
But with no statutory duty on employers, occupational health services declined and were commercialised. Public ownership is essential to ensure accountability to workers’ health rather than to corporate interests.
DiU (MPU) has often provided medical support to trade unions. Currently we offer solidarity and support through UNITE and the National Shop Stewards’ Network. We also liaise with the H&S representatives of other unions and the TUC.
Doctors in UNITE (the Medical Practitioners’ Union) believes there should be National Occupational Health Services (NOHS) for England and devolved nations, including the following criteria:
NOHS should cover all workers, paid or unpaid.
NOHS should address occupational, environmental and commercial determinants of health.
NOHS would provide biological monitoring, employment rehabilitation, and health promotion, and support safety management. We will discuss later whether it should also provide clinical services at the workplace.
NOHS should normally be publicly provided, although where a satisfactory comprehensive occupational health service already exists in a particular workplace, and has the confidence of the trade unions, it could be publicly licensed and its role extended.
NOHS should be accountable to Parliament through a Minister for Industrial Health shared between DHSC, DWP and DBEIS.
They should also be accountable to devolved Assemblies
The existing national organisations for health and safety, employment of sick and disabled people, or control of pollution should be redesignated as part of the statutory comprehensive health service and should review ways to work together and fill gaps. This does not imply any major reorganisation.
Locally NOHS should be controlled by workers (preferably through their trade unions), the appropriate regulatory agency (be that HSE or the local authority), consumer representatives and local communities. In a previous policy statement some years ago, we advocated joint control by employers, expert regulators and trade unions/ communities/ consumers, as that fitted with the tripartite model of health and safety current at the time. However, that model has not proved robust so we now feel NOHS must be controlled by those it serves.
Professional independence is central.
The issue of funding will be raised. In a previous statement we said this needs to come from employers, but funding from general taxation would enhance independence so increases in corporate tax would be better. As health services have a Keynesian multiplier in excess of the figure at which they become self-funding, it may actually not be an issue. At a Keynesian multiplier of 2.5, £1 spent generates £2.50 of growth which generates £1 of tax. Keynesian multipliers for health, education, welfare, recreation and cultural services, care, and social protection are significantly in excess of that – about 4.32 for health – implying that spending reduces the Government deficit.
In smaller and medium sized workplaces, NOHS would be provided on a group basis. For the smallest workplaces (such as a corner shop) it might be provided by the kind of neighbourhood public health system which we have advocated in our paper “Public Health and Primary Care”.
In creating safe and healthy systems of work and in biological monitoring NOHS would feed into a workplace health and safety system which managed the workplace environment, ensured safe systems of work and supported a supportive management of disability and sickness. This system must extend to contractors and volunteers as well as employees.
NOHS and the workplace health and safety system must address stress at work not by victim-blaming “stress management” terms but through the factors in the workplace environment which we described earlier such as autonomy, social networking, training and resourcing of responsibilities, pleasant environments and work/life balance.
There has been much debate about whether occupational health should also provide clinical services at the workplace. This must not dominate and take occupational health staff away from other roles. Many services described as “partial” in 1980 consisted of a factory nurse providing mainly clinical care. This led to doubts about the appropriateness of a clinical role. However, the workplace is a convenient place to provide certain types of health care, including screening, blood pressure measurement, stress counselling and treatment of minor injuries or minor illnesses manifesting at work. There needs to be a system for providing the simple front-line healthcare that in many countries would be provided by a “barefoot doctor” or “community health worker”. This should be planned on a universal basis, so as not to exclude retired or unemployed people, but for those who spend time at a workplace, either as an employee, a contractor or a voluntary worker, clinical care at the workplace could sensibly be a part. In providing such clinical services at the workplace NOHS would be linked to the NHS.
In employment rehabilitation, NOHS would be linked to a Work and Health Service which would take over the disability functions of the DWP, would be part of the NHS (New Zealand is an interesting model here) and would offer employment-focused rehabilitation. Such services were previously operated by EMAS, by Employment Rehabilitation Centres and by Remploy but were inadequately resourced and only operated for the most severely disabled people – at the time we described it as “an excellent icing on a mouldy cake”. Government then shifted the function into a “welfare to work” model which operated too late in the process, missing the opportunity to retain people in work. Both of these systems were separate from the NHS clinical care of the patient, in which work needs to be a central factor.
In addressing the environmental and commercial determinants of health NOHS would be linked to the public health system
NOHS would have access to all levels of management and of regulation.
NOHS needs specialist support from the NHS, laboratory services, environmental services, HSE, public health and academic institutions.
NOHS should be part of the statutory health service. The 1948-74 terminology in which the statutory health service was called “the NHS” should be restored. Even with current terminology there are services NOHS should provide for the NHS, especially front-line health advice, health promotion and employment rehabilitation. NHS bodies may act as local providers of NOHS in some areas.
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