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Health in Scotland 2009 Time for Change: Annual Report of the Chief Medical Officer


CHAPTER 2 Work and health

Most people in Scotland who wish to work, whether in a paid or unpaid capacity, are able to do so. This contributes significantly to maintaining and improving health in all our communities. Good employment is protective of health, whereas unemployment contributes to poorer long-term health outcomes.

Good work, and indeed any meaningful activity (this could be, for example, volunteering or unpaid caring responsibilities), engenders a sense of coherence in life, meeting important psycho social needs in a society where employment is the norm, helping to define an individual's identity, social role and social status. However, jobs that are insecure, low-paid and that fail to protect employers from stress and danger make people ill (Marmot 2010).

Fortunately, even in the current economic climate, the majority of people of working age in Scotland are in paid employment and are able to undertake their work in a safe and healthy environment. Consequently, most of these people will gain a benefit to their long term health outcomes from this work.

However, we recognise that it is important to ensure that those in work are protected from harm in the workplace and are encouraged and supported to improve their health and wellbeing. It has been estimated that ill health in the working age population of Great Britain costs the economy around £100 billion every year (Black 2007). This means that there are important roles for employers, employees, health and safety enforcement agencies, trades unions, and healthcare and employment service providers.

Role for employers

As noted above, by providing work, employers across all sectors make a valuable contribution to improving and promoting health and wellbeing. Employers have statutory duties in respect of workplace health and safety, and, overall, we have a good record in Scotland in minimising work-related fatalities and serious injuries. It is important that we continue to maintain systems in Scotland that support employers to keep their workforces safe and healthy, and that can identify and work with those industries where there is highest risk to workers' safety.

Flexible working that allows employees to fit their work around family care requirements is highly valued by workers. Job design and control over how a job is done, and fair and transparent appraisal and reward structures are also important. Effective and well managed organisations recognise the importance of good management and leadership practices that encourage and promote good health and wellbeing amongst the workforce (Vaughan -Jones and Barham 2010). A wealth of advice and information is available to employers and employees in Scotland from the Scottish Centre for Healthy Working Lives ( www.healthyworkinglives.co.uk).

It is widely acknowledged that employers can be proactive in promoting the health and wellbeing of their workforce. In Scotland we have many examples of good practice where employers recognise the benefit that they can get from supporting good workplace health and wellbeing and in encouraging healthier lifestyles. Many larger organisations offer on-site gyms or subsidised gym membership, healthy choices in canteens, health checks or smoking cessation advice, for example. Other measures can include safe cycle storage, showers and lockers to encourage running or cycling.

Employers who create a positive work environment and culture, and undertake activities that promote employee health do so, not for altruistic reasons, but because they recognise the benefits that it brings for the organisation. Workers who have better health and wellbeing are more motivated and productive, they take fewer days off sick and are more likely to remain with the organisation ( PWC 2007). All of this adds to the bottom line for the employer. The employee's health benefits as well, contributing to longer term employment prospects. In effect a win-win outcome.

However, it is important to recognise that many smaller organisations do not have the resources to offer the type of support described above and that there are other less direct workplace practices that can equally contribute to wellbeing.

The Scottish Public Sector

Around a quarter of the working population of Scotland work in the public sector. As well as the importance this has for the economy, it presents an enormous opportunity for the public sector to take the lead in promoting health and wellbeing to its workforce and beyond to their families and communities.

Many public sector organisations have already demonstrated a commitment to workplace wellbeing through the attainment of a Healthy Working Lives Award, including the Scottish Government. There is, however, always room for improvement. The Scottish Government is working with NHSScotland and with COSLA to develop a public sector mandate on health and work. The intention is to empower the public sector to take a coherent approach to workplace health, safety and wellbeing, attendance management, occupational health and work rehabilitation and return. It is important that these are approached as a whole system and not separate, siloed areas of activity.

The Boorman review of the health and wellbeing of the NHS workforce in England (Boorman 2009) identified the close links between good staff health and wellbeing and improved clinical outcomes. The review concluded that NHS sickness absence in England could be reduced by a third from its current rate with an estimated direct cost saving of approximately £555 million. The recommendations of the Boorman review are well worth considering both for the NHS in Scotland and for the wider public sector.

Dame Carol Black's review of working age health in Great Britain recognised the need for the inclusion of Occupational Health within mainstream healthcare. There is a challenge for the occupational health and vocational rehabilitation communities to establish clear professional leadership for supporting the health of all working age people.

It is equally important that other parts of the Scottish Public Sector adopt these principles, particularly local government which employs a significant proportion of those working in the public sector.

The sharing and adoption of good practice across the public sector is more critical now than ever to ensure that the benefits of improved motivation and productivity, and reducing sickness absence can contribute to maintaining public services.

Impact of the recession

The impact of the economic recession is being felt across the whole of the Scottish economy. This can have serious repercussions for health amongst the working age population, both for those in work and those seeking employment. We know that unemployment has a negative impact on health, but also that returning to work very quickly starts to improve health and wellbeing (Waddell and Burton 2006).

For the newly unemployed it is important that they receive advice on maintaining their wellbeing while looking for work and that the contribution of unemployment is recognised by healthcare professionals when supporting these people.

Employers too, should consider the impacts of restructuring their organisation. As well as the negative impact of health on those losing their jobs, the workers that remain can also experience poorer health, including worry that they might be next, the impact of work intensification or stresses from working in new and unfamiliar structures (Kieselbach et al 2007). Employers can mitigate some of the effects of restructuring by ensuring that they involve the workforce in job design and delegate reasonable control for how individuals and teams do their work.

Implications for healthcare services

For those people with a health barrier to remaining in or returning to work, the attitude of healthcare professionals towards the relationship between health and work is critical.

As well as providing health benefits, work can be a part of the recovery and rehabilitation process. It is important that the patient's work status is recognised and that the patient's health care plan supports them either to return to work or to access employability services that will move them towards work. If the patient is in work, they will need to be given sufficient information and support to discuss returning to work with their employer. If they are out of work, then the discussion should be started early enough for other services such as Jobcentre Plus or other employability advice and support to be accessed in a timely manner.

The introduction of the 'fit note' to replace the sicknote has moved us a significant way to encouraging health professionals to consider the importance of work. However, we wish to do more. The Scottish Government is working with a wide range of healthcare professionals to develop a 'Scottish Health Offer' which will set out principles and standards for provision of health services to those with a health barrier to work. This will improve the recognition by health professionals of the important contribution to health that work can make and the confidence and skills of staff to incorporate work issues in their interaction with patients.

Welfare benefits

As I have pointed out above, it is as important to address the health barriers of those out of work as it is for those in work to enable as many people as possible to get the benefits of participating in some form of meaningful activity. Most people will, with the right support, be able to manage their condition sufficiently for them to do so.

It is important, however, that the benefits system itself does not create barriers to entering into work. Prolonged time spent on benefits erodes health and wellbeing, and makes re-entering work increasingly difficult. I would hope that the reforms of the welfare system proposed by the new government in Westminster will ensure that any existing welfare barriers to work are removed and that no new ones are erected, whilst ensuring that sufficient support remains for those that need it. It is particularly important that people who are moved from health-related to job-seekers benefits are not then abandoned to find work themselves. Otherwise we will surely see them again shortly, likely in a more incapacitated state than before.

At the time of writing, DWP have indicated the ending of their Condition Management Programme in March 2011. Those with health conditions who would return to work will continue to need access to support for their condition and the Scottish and UK Governments will need to work together to ensure this need is met.

An ageing workforce

We are entering a period when the first of the baby boom generation are starting retirement and the last are moving into late middle age. This means a significant proportion of the working age population are in their 50s and early 60s, with an increasing prospect of having to work longer before retirement. We can expect this cohort to develop the common, long-term conditions of late middle age - for example arthritis, diabetes, osteoporosis - as well as conditions such as cancer, where people can often continue to work. This will present challenges for both healthcare services and employers. The NHS will need to recognise the need to help keep this population as healthy and active as possible and to include work in care pathways. Employers, too, will need to recognise that they can contribute to keeping their workforce as healthy as possible, while also understanding the need to make adjustments in workplace practices to allow workers to receive healthcare or to manage their conditions.

The next generation

Given the demographic make-up of the current workforce and the changes over the next 10-20 years it is more important than ever that the next generation of workers are ready and able to fully participate in the jobs market. These workers will need to better appreciate the important links between work and health, to accept that they have responsibility for maintaining their own health, but also to have an expectation of employers responsibility to look after and promote the health and wellbeing of their staff. There needs to be room in the curriculum to prepare young people for the world of work and to let them know what can be expected of them and of their employers to ensure that they can all benefit from employment.