A National Occupational Health Service

Doctors in Unite Policy Paper, September 2021

SUMMARY

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:

Cover all workers, paid or unpaid.
Address occupational, environmental and commercial determinants of health.
Provide biological monitoring, employment rehabilitation health promotion and support safety management.
Normally be publicly provided
Be accountable to Parliament and devolved Assemblies.
NOHS should be part of the statutory health service.
Existing national organisations for health and safety and control of pollution should be redesignated as part of the statutory comprehensive health service. This does not imply any suggestion for reorganisation of them.
Locally, NOHS should be democratically controlled by workers (preferably through their trade unions), the appropriate regulatory agency, consumer representatives and local communities.
Professional independence is central.
Funding from general taxation to enhance independence.
Be provided on a group basis to small and medium-sized enterprises.
Stress at work must be addressed.
Certain types of health care should be provided in the workplace.
Linked to a Work and Health Service taking over DWP’s disability functions, as part of the NHS and providing employment-focused rehabilitation.
Linked to the public health system.
Have access to all levels of management and of regulation.
Have specialist support.

THE IMPACT OF WORK ON HEALTH

By comparing variance between industries in age/sex standardised mortality and in age/sex/social class standardised mortality, Fox & Adelstein showed in the 1970s that between a quarter and a third of UK social class variance in health was caused by work, rather than by lifestyles, housing, geography or general economic and social conditions. The 20,000 annual UK occupational deaths implied by this was far more than have ever been recognised as occupational deaths, suggesting unrecognised or unquantified work-related causes of common diseases. The study has not been repeated, and some data is no longer routinely collected. In the ensuing four and a half decades a shift from manufacturing to service industries has exported some of former occupational causes of disease to countries with weaker regulation and weaker trade unions. However new forms of unhealthy work have emerged, whilst trade unions and regulation have both been weakened. The figure may not have changed, especially as the proportion of the variance which it explains by work is similar to the proportion of adult life spent at the workplace.

Work can be bad for health but so is unemployment. Good quality work is needed– safe work in which people are trained and resourced for the responsibilities they carry and have control of their own work and work/life balance. Poor quality work and worklessness both damage health. The most disadvantaged suffer unemployment in recessions and poor-quality work in economic growth, never experiencing good quality work and suffering two different health-damaging situations successively.

Employment, through its impact on well-being, is central to both physical and mental health. Social networks help protect against a wide range of physical conditions including cancer and complications of pregnancy. Lack of autonomy harms cardiovascular health. Threats hanging over people that they cannot influence cause a stress reaction which contributes to heart disease, cancer and infections. This is also caused by people carrying responsibilities that they are not trained or resourced to carry (although responsibilities which they are able to discharge are a healthy challenge rather than a stressor). Pleasant green environments are of sufficient importance that people recover faster from surgical operations if they can see a tree from their hospital window. Work/life balance and understanding of family roles are important to avoiding the stress of role-conflict.

THE IMPACT OF HEALTH ON WORK

Work in a safe and supportive environment has a positive effect on health. The consequences of long-term unemployment are well known. Work can be an important contributor to health resilience. Unfortunately, sickness and impairment can often prevent the obtaining of this essential support.

People with impairments should be employed for their abilities not viewed through the lens of their impairment. Most people with impairments can work in an appropriate setting. However, this doesn’t routinely happen. If people become sick, they may well lose their job. The welfare to work policy is stigmatising and punitive in approach, itself damaging health by causing stress and diminishing self-respect.

OTHER IMPACTS OF WORK AND ECONOMIC ACTIVITY ON HEALTH

As well as occupational ill-health, economic activity can damage health in other ways. It may cause pollution, harm the environment, produce products that are less safe and healthy than they could be, or market unhealthy lifestyles encouraging people to harm themselves.

OCCUPATIONAL HEALTH SERVICES

It was said in 1980 that a comprehensive occupational health service would provide biological monitoring, employment rehabilitation, clinical services at the workplace and health promotion, and feed into a workplace health and safety system which managed the workplace environment, ensured safe systems of work and supportively managed disability and sickness.

At that time about a third of the workforce had a comprehensive occupational health service, about a third had a partial service and about a third had no occupational health service at all. Large employers were more likely to have a comprehensive service and smaller workplaces more likely to have a partial or non-existent service.

Since 1980, the closure of large sectors of manufacturing and heavy industries, privatisation of nationalised industries, and growth of service industries perceived as less hazardous, has led to outsourcing of most occupational health services to commercial companies. Insecure contracts and separation from the workplace culture mean they have less independence than the old-style services.

Comprehensive services as defined in 1980 are now virtually unknown, limited to some especially hazardous and regulated industries like the NHS, nuclear industry and armed forces. The majority of the workforce now have no access to occupational health services. For many who do have access, it is not a direct access.

HISTORY OF ORGANISATION OF OCCUPATIONAL HEALTH SERVICES

Occupational health services in this country have never been a statutory service. Some public bodies provided occupational health services for their own staff (although they have often now been outsourced) and some NHS bodies have contracted to provide occupational health services to private companies. However, the context has been employer-provided services rather than a public duty.

Nye Bevan wanted occupational health (including the Factories Inspectorate) as a fourth wing of his NHS, and was supported by the BMA, but opposed successfully by others. What Nye called “the NHS” was broader than what has been called the NHS since 1974, and meant what since 2013 has been called “the statutory health service” (or, as Andrew Lansley called it “the comprehensive health service”) i.e. health care and public health. Between 1948 and 1974 the environmental health services of local authorities were part of one of the three wings of the NHS and this wing of the NHS cleaned the air, cleared the slums and eradicated polio and diphtheria. Between 1974 and 2013 these services were not part of the NHS, or of the statutory health service established under the NHS Acts. Since 2013 they have been restored to the statutory health service but continue to be excluded from the term “the NHS”. Doctors in UNITE believes in restoring the pre-1974 terminology.

Throughout the 1950s and 1960s there was a campaign to incorporate occupational health into the NHS. This can be misunderstood if interpreted in the light of the current terminology rather than that current at the time. The Health & Safety at Work Act, 1974 occurred in parallel with the reforms of the NHS which redefined it so as no longer to include environmental health. Thus the possibility of the new health and safety bodies being part of the NHS was never considered.

In 1980 occupational health again came to the fore of political debate but by 1980 the new definition of the NHS had bedded in so the debate about occupational health being part of the NHS had come to be seen as a quaint, reactionary, medicalisation of the issue. The MPU did articulate the case for restoring the old definition of the NHS and adding occupational health to it, but this required two separate reforms to take place together. The TUC shared the general consensus that occupational health was working well in large workplaces and group services were needed for smaller workplaces. However radical GPs in Sheffield were also trialling accessible focused primary care services supporting workers with occupational health problems. These spread at the time to a number of other cities but, following years of austerity cuts, only the Sheffield one remains.

The hope in 1980 was that the system would grow and ways would be found to make it universal. Public ownership was seen as a distraction.

These hopes were not met. Without any statutory service, and without even any duty on employers to provide a service, it gradually declined. Far from being a distraction, public ownership is essential to ensuring a primary accountability to the health of the people rather than to corporate interests.

SUPPORTING WORKERS ON OCCUPATIONAL HEALTH ISSUES

As the medical organisation of the social movements of the people DiU (MPU) has always sought to provide medical support to the trade union movement. In the 1950s the union’s full time Medical Secretary did this. In the 1970s we made a medical input into the work of the ASTMS Health & Safety Office. In the 1980s volunteers from within our membership, called “medical safety representatives” aimed to provide such advice to workers engaged in health-related collective bargaining, and we also contributed to the training of safety representatives in what was then the GMWU at its national college. Currently we offer solidarity and support through UNITE and the National Shop Stewards’ Committee. The trade union movement needs access to medical advice which is sympathetic to grass roots collective bargaining. We have a role in that, although we do not claim any exclusivity.

A FUTURE OCCUPATIONAL HEALTH SERVICE.

The term “occupational health service” is time-honoured with no obvious alternative, but, especially if it is outsourced rather than integral, implies excessive professionalisation of issues which should be integral to workplace cultures. It must be an independent source of expert advice to a workplace health and safety service and to an employment rehabilitation and resettlement service. It should also contribute to addressing the environmental and commercial determinants of health as well as the occupational determinants. “Occupational health” has not traditionally done this. If the new occupational health is to do so it needs links to public health.

Doctors in UNITE (the Medical Practitioners’ Union) believes there should be a national occupational health service (NOHS) meeting 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.