Presentation by dr. Dame Carol Black, UK National Director for Health and Work at the WHO/TNO/Dutchgovernment Congres 'Connecting Health and Labour' 29 - 1 December 2012

1. WHO International Conference
What role for OH in Primary
Healthcare?
The Hague, 29 November 2011
Occupational Health:
a challenge for
primary healthcare
Dame Carol Black
UK National Director for Health and Work

2. The fundamentals: work is a
social determinant of health
Galen (129-200)
Employment is nature’s physician • Work is generally good for health
and is essential to human happiness. Waddell and Burton, 2006
• That work is good for man is
supported by evidence and
consensus. The physician‟s role is
to encourage work, and return to
work, as part of treatment.
Talmage and Melhorn, AMA Press 2005
Family doctors and other health professionals in the primary
care setting should be engaged and involved.

3. The key players
Health professionals
(Primary and secondary care)
Employers Employees
(Line managers, (Patients)
Human Resources)
OH professionals
(less than 15% of the global workforce has access)
These are crucial relationships that vary according to
process and practice in different countries

4. The needs of the worker
• to be healthy enough to work
• safe healthy workplaces - physically safe
- emotionally healthy
• good work:
- job security
- work varied and interesting
- workers have some autonomy, control and
task discretion
- fair rewards (not just financial) for effort
- supportive social relationships
- worker engagement.
The various countries of the world are at different
stages in providing the above.
The nature of work is changing in many countries.

5. What do we need of
OH globally in the 21st century?
Occupational Health services must:
• suit the current profile of employment
in different countries, as work is changing
• form new partnerships and find new ways of working
across traditional boundaries
• make a greater contribution to national economies
• examine the care pathways for working people, and find new
ways to support them, before, during and after illness
• relate to, and be further attached to, mainstream healthcare
(primary and secondary) and relevant specialties.

6. What do we need of our
health professionals in primary care?
• an understanding that work is a determinant
of health
• return to function, therefore often to work,
should be a desirable clinical outcome
• a focus on capacity not incapacity
• an understanding that you do not have to be
100% fit to work
• ability to take a good occupational history and
act upon it
• communication and collaboration with other
key players.

7. The old UK system, and
the need for change
Old system
• Work-related ill-health is often not
life-threatening, but life-diminishing, GPs issued
e.g. common mental health problems „sick note‟
and musculo-skeletal problems.
• No clear pathways of rehabilitation,
and treatment too often slow and
inefficient, often with a poor outcome
for the patient.
• GPs have no easy access to expert
assessment or OH advice
• Three-quarters of employers have no
access to OH.
• Repeated medical Notes can lead to (the benefit system)
worklessness – this is Bad Therapy!

8. What are we doing in the UK for
Health Professionals in Primary Care?
• Education, training and information to enhance their
understanding and knowledge
• Encouragement of those family doctors who have special
interest in OH to become more involved, with training
programmes and qualifications
• An improved „medical certificate‟, focusing on capacity not
incapacity
• Early-intervention case-managed service available, in some
areas, for referral by GPs
• Telephone helpline for OH and other queries
• Proposal, just announced, for an early
Independent Assessment Service.

9. Central role of education and training
for healthcare professionals
• „Healthy Working UK‟ – a
comprehensive web-based resource for
primary health professionals
• „Health and Work in General Practice‟
– national education programme for GPs
• „Health e-working for primary care‟ –
a modular e-learning package for
primary care
• „Health e-working for secondary care‟
– a modular e-learning package for
secondary care
• Royal College of Nursing – web-based
programme
Programmes are in place for GPs, secondary care, nurses, therapists

10. The UK national education
programme for GPs – the next steps
• Enhance engagement with employers across the UK
• Employer-funded training model for GP health and work
training
• Enhances the reputation of the businesses through links
with accredited RCGP training
• September 2011 – August 2012, 40 workshops across
the UK arranged
• Attendance between 8 – 35 delegates per workshop
• Further requests from businesses for training sites
• GP trainees now requesting training programme as well

11. From „sick note‟ to „fit note‟ in UK
Sick note: Now GPs share responsibility with employers
• GP knows health condition and impact
• For the previous
eighty years or • Employer knows job
more, a GP (family • Employee knows complexity of absence
doctor) assessed a
person’s health and Adjustments being made:
ability to work. • Phased return to work
• The old form • Part-time working
required the doctor
to state whether or • Working from home
not the patient could • Flexible start times
work, and how long
• Different tasks
they should refrain
from work if sick. • Practical adjustments in the
• Partial ability to
workplace.
work was not
considered. Family doctors have crucial „gatekeeper‟ functions.

12. GPs‟ attitudes towards patients‟ health and work
GP responses to the statement: The Fit Note has….
70%
60%
60% 54% Fully agree .... fully disagree
48%
50%
42%
40% 36%
30% 26%
20%
13% 12%
10%
10% 7% 5% 6%
0%
Improved quality of Improved advice I
Improved patient IncreasedIncreased Helped patients Increased lengthmyMade no changes
Helped my Increased of
discussions with give to patients frequency with make a phased my consultations to my practice
discussionabout about their fitness which I recommend patients work
patients
frequency of return to
make consultation
for work advising to work as phased return
return toImproved work
work return return length Not changed
advice given to to workto recovery to work
aid as aid my practice
Completely patients
Agree to recovery
Somewhat Agree Somewhat Disagree Completely Disagree
99% of GPs agree that work is generally beneficial for
people‟s health – this attitude must be translated into action.
Source: GP Attitudes to Health and Work Survey

13. Work-related health advice in
primary care
• Collaboration project between University Hospitals of Leicester OH lead and
the Orchard Medical Centre at Broughton Astley
• Provides services for 30,000 people, including NHS staff
• Pre-booked 30 min appointments with two GPs with an OH background were
offered for work-related heath consultations
• 96 patients were referred or self-referred over 12 months – patients responded
positively to the provision of an OH clinic in their general practice
• 30% of consultations resulted in a letter being sent to the patient's employer or
line manager
• 13% were referred to their workplace OH provider
• None were referred to a specialist OH professional
• 33% had mental health problems
• 51% were on sick leave at the time of their consultation
• OH services in primary care does not attract any quality framework payments
De Bono et al (2011) Occupational Medicine

14. Fit for Work Service pilots – co-ordinated
early health and work support for individuals
Aim - To reduce sickness absence and avoidable job
loss, through co-ordinated services (began April 2010)
How
• Service for people off work sick after 4 to 6 weeks
• Pilots in locations across GB, GPs encouraged to refer.
• Early access to co-ordinated health treatment and
employment support, including debt, housing, learning
and skills, employer liaison, conciliation
• Case-management a key component
• Variety of delivery partnerships – existing and new local
consortia
• Identifying underlying problems with rapid referral
• One-stop supported approach
• Practical support in non-medical areas
• OH input as required
In the first year, 6,500 people sought help To help people remain in work or
from eleven Fit for Work Service pilots return to work more quickly
across Great Britain.

15. Fit for Work Service
in a region of England
Convenient for patients Musculoskeletal 15%
• Contact within 24hrs
• First appointment within a week Mental Health 7%
• Mobile phone communications
Mediation/Negotiation 38%
• Wide choice of venue for consultation
Helpful to GPs Personal Support 17%
• Ease of referral – no forms
Help with new 23%
• Musculoskeletal interventions funded employment
• Service signs Fit Notes
• Service provides audit data to GP
practices
60% returned to work i.e. 78% non-medical
Leicester FFWS

16. Occupational Health Advice Helpline
0800 077 8844
• Provides GPs and businesses with tailored occupational health advice,
by advisers with special training in Mental Health.
• Most callers are calling about an individual person’s case
• 95% of callers appreciate the contact, and 92% would recommend to
colleaguess
42% calls about sickness absence
24% calls are about the fit note
20% calls are about mental health
(anxiety, depression, stress, and
other mental health conditions)
19% calls are about health surveillance

17. Independent Review of Sickness Absence
Published 21 November 2011 – recommendations to UK Government. Example:
“ We therefore recommend that the Government should fund a new Independent
Assessment Service (IAS), usually to be accessed when an individual’s absence
spell has lasted around four weeks. It would:
• provide an in-depth assessment of an individual’s physical and/or mental
function
• provide advice about how an individual taking sickness absence could be
supported to return to work
• be provided by approved health professionals and
• be appropriately quality-controlled.
The IAS is intended to improve the effectiveness of medical certification and to
encourage early positive intervention. “
Carol Black and David Frost, November 2011

18. Final thoughts....
“If you keep on doing the same
things and expect things to
change, then that‟s a definition of
insanity.”
“The future has many names. For the
weak it is unattainable. For the fearful it is
unknown. For the bold it is opportunity.”
Victor Hugo