In establishing the modern welfare state, the 1942 Beveridge Report recognised the link between work and health. Yet more than 75 years after the founding of the NHS, the state still does not provide support to keep workers healthy and in work.
This has perhaps never been so important. According to the Office for National Statistics (ONS), the estimate for the number of people who are economically inactive due to ill health has increased from 2.6 to 2.8 million. More than a fifth of the working-age population (aged 16-24) are neither in work nor looking for a job, and 4 per cent of the UK overall population have long-term health issues.
For a time, it was reasonable for policymakers to think this trend was a hangover from the pandemic; but now, more than two years later, that is wishful thinking. Worklessness due to ill health will remain a drag on the economy and on the lives of many unless a strong response is found.
Occupational health – the specialism that aims to keep workers healthy and workplaces safe – has long been part of the answer. It includes support for those with mental health issues that might prove a barrier to staying in work, and also for those with musculoskeletal issues, which are also a common inhibitor to employment. The evidence base is clear in showing that occupational health interventions help people with disabilities and long-term conditions stay in work and increase productivity across the workforce.
Prime Minister Rishi Sunak’s plan to review the system of fit notes, or sick notes, will only partly meet the challenges the UK faces. Blaming “sick-note culture” will not help. What the UK needs is the right support to help people stay in work. Fit-note certification should include an active review, with a triaged referral to an occupational health professional to support people remaining at, or returning to, work. A lack of basic skills in occupational health is a barrier to using the fit note to its full potential; fit notes should be reviewed by health professionals who are trained in occupational health.
When people see their GP team, they can often expect an all-or-nothing “sick note”. This makes it harder to manage patient expectations. The “may be fit for work” option also exists but is not used as often. Discussing the merits of this option, or a shorter review period before reassessment, can be perceived as punitive by patients who expect to get “signed off” and find it difficult to understand why their GP team would challenge this. Tailored occupational health advice should be made available to patients who receive the fit note, with more consideration for this third option.
The problem is ultimately, however, that occupational health is not universally accessible to help people stay in and return to work. The NHS has never provided it for the general population. While larger employers do tend to provide private occupational health support, that is not feasible for many small and medium-sized businesses (SMEs), and support is completely absent for those who are self-employed or working in the gig economy.
At present only about half of the workforce has access to occupational health services. In a post-pandemic world of Long Covid and increasing prevalence of mental health issues and chronic conditions, this is not good enough.
A key part of tackling economic inactivity must be ensuring universal access to occupational health. Put simply, everyone who needs support to stay in work should have access to it. The response needed from policymakers to achieve universal access is affordable and straightforward to implement.
First, we must increase the proportion of employers offering occupational health services. This means clearer obligations on larger employers to provide occupational health services for their staff, with penalties from the Health and Safety Executive if they do not. It will also mean greater government-led advice and support for smaller employers to improve their overall work performance through better working practices that support health and prevent illness. This would include email and telephone advice services, downloadable resources and workplace visits. The Healthy Working Lives Scotland programme is an existing, successful model.
Second, the NHS must play a central role in extending support to small-business employees and the self-employed.
As far back as 2008, Carol Black’s report, “Working for a healthier tomorrow”, emphasised the importance of occupational health being “brought into the mainstream of healthcare provision” and embracing “closer working with public health”. Work carried out for the Society of Occupational Medicine shows that this is achievable at relatively low cost and with the need for no more than a few hundred additional clinicians and a few thousand case managers. Core occupational health services could be funded regionally and provided by expanded NHS Hospital Occupational Health departments (which currently only provide services to NHS staff). A modern service would allow for self-referral or referral from employers, to sit alongside referral by GPs.
In the context of the growing number of people who are economically inactive, the challenge of ill health at work must be urgently addressed. Workers have the right to support that helps them stay healthy in work, and to stay in work. Universal access to occupational health would meet that need.
[See also: Dispatches from the land of Long Covid]
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