Health and work strategy: review report

11 Underpinning Fair and Healthy Work

Recommendation 4.1

Bring Health and Work and Fair Work together in policy terms.

Implementation

• This could be achieved either by incorporating Health and Work within Fair Work, or establishing a cross Government Health and Work Policy Unit akin to arrangements in England.

Evidence/Rationale

Fair Work and Health and Work are closely related and there is significant scope for more effective collaboration and efficiency, and coherence in terms of programme delivery for employers and service users. The Health & Work Support pilot is a good example of how such collaboration can deliver on both agendas.

The recently published Fair Work Action Plan^[12](2019) proposes a set of actions, a number of which parallel those proposed by the review of Health and Work and which could be extended to embrace the health dimension more explicitly than is currently the case. These include:

• Embedding Fair Work across Scottish Government portfolios;
• Fair Work First;
• Online service for small and micro employers;
• Measuring progress in delivering a Fair Work Nation.

Target Audience

Employers, employees, self-employed.

Stakeholders

Scottish Government Health Improvement Directorate and Fair Work, Skills and Employment Directorate.

Cost

Making health explicit within the Fair Work agenda is unlikely to require significant cost, indeed may even result in more effective use of resources that could release investment that for use in other areas of the agenda. Implementation would, however, require resources to be either pooled or moved between existing Government policy areas.

Complexity

Relatively straightforward given this is directly within the powers of Scottish Ministers and the two Directorates have a good pre-existing relationship.

Impact

Improved co-ordination of the policy and delivery response to enable Fair and Healthy Work in Scotland, and a more coherent and therefore accessible set of messages for employers and employees.

Recommendation 4.2

Fair and Healthy Work to be an explicit priority across all Directorates of Scottish Government and its national agencies.

Implementation

• Include Health and Work within the work-stream to embed Fair Work across Scottish Government Portfolios.
• Fair and Healthy Work to feature explicitly within work to implement the Scottish Public Health Priority of Inclusive Economy.
• The public sector, including the Scottish Government, to be an exemplar in terms of the practice of Fair and Healthy Work.

Evidence/Rationale

Health and Work has traditionally sat within the policy domains of Public Health and Occupational Safety and Health but the bio-psychosocial and economic impact of work should make it a critical focus of work across Government. As such it relates directly to Fair Work as set out in recommendation 4.1, and it would be logical to extend the Fair Work Action Plan proposal to embed Fair and Healthy Work across Scottish Government portfolios.

Linked to this is the importance of the public sector, including the Scottish Government, being exemplars for Fair and Healthy Work, as is currently the case with the Healthy Working Lives Award. It also fits within the role of public sector bodies as Anchor Institutions^[70] within local areas. The public sector is critical as an employer as well as for the wider impact is has on the community, and without its explicit leadership commitment it is also more difficult to encourage buy-in by other sectors of the economy, and the public sector is also able to play the role of a test bed for new practice.

Inclusive Economy is one of the Public Health Priorities for Scotland and is the priority to which Fair and Healthy Work relates, though there is no explicit reference to Fair or Healthy Work, or indeed to Good Work^[20]. This introduces the risk that the priority may not feature as clearly as it should in terms of public health implementation. Including explicit reference to Fair and Healthy Work within work to implement the Public Health Priorities for Scotland would be a very welcome, and in terms of setting an example, a crucial step.

It is also important not to lose sight of the fact that workplaces are a vital 'setting' for health improvement activity^[19], though this must be within the principle of proportionate universalism^[20] which states that the resourcing and delivering of universal services at a scale and intensity must be proportionate to the degree of need in order to enable health inequalities to be addressed.

Target Audience

Scottish Government, Scottish Government agencies including the NHS, local authorities and academic institutions.

Stakeholders

As above, plus employers, employees, the self-employed and trades unions.

Cost

Cost in not likely to be significant and any investment would be at the level of each individual organisation who would also recover benefit in terms of reduced absence and presenteeism, and improved productivity.

Complexity

Relatively straightforward in the sense that a number of mechanisms already exist that can be extended or in which Fair and Healthy Work can be made more explicit.

Impact

Extending the work to embed Fair Work across Government, by including in it the health dimension, will result in health impact that may otherwise not occur. Doing so also sends a crucial message to other sectors of the economy about the priority that needs to be placed on Fair and Healthy Work.

Recommendation 4.3

Establish a single, integrated National Occupational Health body for Scotland.

Implementation

• Review the current arrangements and training needs for specialist occupational health within the Scotland Public Sector (medical, nursing, workplace advisors) required to provide consistent, quality support for public sector employees and externally to SMEs and the self-employed with a view to establishing a single, integrated Occupational Health body for Scotland within the NHS.
• Consider options for a long-term funding model for this new body that balances the costs and benefits between stakeholders.

Evidence/Rationale

The impact of demographic change and the predicted increase in multiple long-term conditions impacting the workforce will require ever greater preventative and management action, yet the majority of employers lack access to the specialist advice they require to do this, a problem that is particularly acute for small and medium sized employers. The growth of the gig-economy has led to people who would previously have been considered 'employees' being designated as self-employed who now lack what access they previously may have had through their employer.

The current occupational health workforce, which includes occupational health doctors, nurses and allied health professionals, case managers and advisory staff, is relatively small and highly fragmented and there are issues of recruitment, training, retention, quality and inconsistency of provision^[47]. Within the public sector, the bulk of the workforce is located within the NHS, with public sector organisations without in-house provision sourcing their occupational health support either from other public sector bodies or from private sector providers.

In her review of the health of Britain's working age-populations, Dame Carol Black made the case for an "integrated approach to working age health underpinned by the inclusion of occupational health and vocational rehabilitation within mainstream healthcare^[2]," a recommendation that was not acted upon. Ten years on, the case for this is even stronger, and Scotland has the advantage of having the right scale and the relevant powers to make it happen.

Bringing together existing public sector provision in the first instance would create a sizable new organisation and would be expected to bring some efficiencies, however stepping-up provision to meet future needs will require new investment. Given the benefits of occupational health are shared between employers, employees, the NHS and the wider state^[69], such as through lower social security costs and increased tax take, work taken forward to design the new body should include consideration of a long-term funding model for given the benefits accruing.

Target Audience

Employers, Employees, the Self Employed, and those with a health condition seeking work.

Stakeholders

Scottish Government, Public Sector Agencies including the NHS, Local Authorities, Employers, Trades Unions.

Cost

Specific work will be required to scope the role and resources required by the new organisation, as well as a sustainable funding model.

Complexity

This will be a highly complex piece of work that will take time, resources and commitment to deliver, and the new organisation will require the right leadership, governance and accountability. The work could be expected to impact upon a large number of organisations, both in terms of the occupational health provision they receive and on those staff responsible for delivering it. As such a working group comprising a minimum of Scottish Government, existing providers, recipients of services, the different occupational health workforce stakeholder groups and trades unions would be required to take detailed thinking forward. In the short term it may be desirable to bring nationally organised public sector occupational health provision into a single organisation and develop the wider body from this base.

Impact

The evidence base for the impact of occupational health and wellbeing is significant^[2,23,47], and bringing occupational health together in single national organisation can be expected to bring the benefits of scale and ensure the long-term sustainability of occupational health in Scotland. A new national organisation would also be positioned to provide occupational health leadership and expertise to support the wider health and social care system, such as in the case of the proposals outlined in relation to developing a Scottish Fit Note (Recommendation 3.1) and maximising the role of the wider NHS (Recommendation 4.4).

Recommendation 4.4

Maximise the role of professionals in the wider health and social care system to consider how they can actively contribute to helping people access, remain in and return to fair and healthy work.

Implementation

• Establish a Managed Clinical Network (MCN) with a remit to develop detailed proposals for how health and social care professional practice can more effectively support people to access, stay in and return to work.

• This work would also need to consider the training requirements for existing staff and the next generation of health and social care professionals.

Evidence/Rationale

Enhancing the role of healthcare staff in supporting people to access, stay in and return to work as an important outcome of a clinical intervention has featured in a number of strategies over the last decade^[2,4], but has not been taken forward in a systematic way. The review of Health and Work endorses the importance of this work and has reflected on the reasons for this approach that should be taken to deliver the ambition.

The Review has concluded that the most appropriate way to take this forward is through a Managed Clinical Network (MCN) charged with providing the necessary high-level leadership and stakeholder engagement, to develop details proposals for how to broaden the current medical approach and enabling the patient to attain the best functionality possible for them to engage with work. The MCN will be responsible for developing, amongst other things, the metrics, indicators, and the training that would be required for each professional group and to develop the next generation of NHS staff. This MCN will require appropriately senior membership from clinical bodies working within the health and social care system, including occupational health/workplace health, in addition to patent, employer, employability and trades union representatives.

This work would naturally sit alongside the development of an Occupational Health Body that would provide the specialist support to professionals within the wider healthcare system.

Target Audience

Health and Social Care Professionals

Stakeholders

Scottish Government, NHS, Local Authorities, health and social care professional bodies, employers, trades unions, patients.

Cost

The principal costs will be associated with training. Part of the role of the MCN would be to clarify the appropriate level of OH training and support for each professional group to enable them to undertake their role.

Complexity

Despite the potential for the wider role of the NHS in health and work being highlighted on a number of occasions over the last decade, the fact that this potential has not yet been realised is indicative of the complexity involved. There are many stakeholders involved, and there is a need to balance what is clinically possible with what is operationally desirable, and there is also the need for clear and committed leadership. An MCN is therefore proposed as the mechanism for achieving the ambition

Impact

The impact of the whole health and social care system being equipped to contribute to the outcome of Fair and Healthy Work cannot be understated, and if achieved would result in the step change aspired to in the commissioning of this Review.

Recommendation 4.5

Undertake targeted marketing to ensure employers are aware of sources of support and advice, including service support for their staff, and employers make use of them.

Implementation

• Invest in a marketing strategy with realistically budgeted annual marketing plans that are co-ordinated with other agencies targeting employers and employees.

Evidence/Rationale

Market research undertaken for Healthy Working Lives^[61,71]and the Fit For Work Scotland Service^[72] provide a clear steer for the approaches to be taken to the marketing of health and work services and messages to employers. These include the need for a clear call to action, the importance of tailored messages for different stakeholder groups (employers by size and sector, employees, GPs, etc.), that multiple brands are confusing and to be avoided, the need for a clear channel strategy, and that campaigns are co-ordinated to avoid overwhelming an already busy audience who may not consider health and work to be a priority. Experience also shows that regular marketing is required to maintain the engagement of target audiences.

Collaboration between Scottish Government initiatives would prevent duplication of effort and a much more focused approach to priority audiences. We know, for instance, that 470,000 people working in Scotland are not being paid the real living wage^[73], and it is a reasonable working assumption (that will nevertheless require testing) that a range of Fair and Healthy Work related issues affect the same cohort of the population. Pooling resources to target the employers concerned would result in maximum impact. It would also promote a closer working relationship between the policy areas of Health Improvement and Fair Work, Skills and Employment.

Such an approach should not, however, replace an overall population health approach which should remain guided by the principal of 'proportionate universalism proposed by Professor Sir Michael Marmot^[20].

This recommendation relates to recommendations 2.1 and 2.2 in terms of the programmes being marketed.

Target Audience

Employers, employees and the self-employed. Intermediaries who can promote messages to these audiences.

Cost

The cost of marketing varies considerably depending on its scale in terms of the size of market being reached and the channel that is employed, and there is also value in on-going market research and tracking to measure impact and inform both strategy and implementation. Experience tells that an annual budget of less than six figures would achieve little in terms of impact.

Complexity

Marketing health services and messages to employers is highly complex and required considerable expertise such as that developed within the marketing team of NHS Health Scotland. Market research undertaken in Scotland in support of services including Healthy Working Lives and Fit For Work Scotland provides the insight to ensure implementation is as effective as it can be.

Impact

When delivered well, marketing can deliver significant impact in terms of engaging employers in health and work programmes.

Recommendation 4.6

Ensure on-going strategic oversight to ensure policy and practice is responsive to the rapidly changing employment and workplace environment.

Implementation

• Ensure constant and coordinated strategic review and oversight including data (observatory) and intelligence (research), horizon scanning and monitoring and reviewing progress and impact.
• Regular Health and Work stakeholder summits, which could be integrated into the Fair Work summit proposed in the Fair Work Action Plan.

Evidence/Rationale

The nature of work and the labour market, and their relationship to individual and public health is rapidly changing and it is important to remain responsive in terms of policy and practice. As an example, Andrew Pulford of NHS health Scotland is currently undertaking doctoral research into the relationship between precarious employment and health outcomes amongst Scottish working age adults. Outputs from this research which will be published over the coming four years, will have relevance for the Fair and Healthy Work Agenda going forward.

Bringing stakeholders together on a regular basis to consider new data and evidence, review progress and consider next steps should be done regularly. The Review Advisory Board could be starting point for this, though collaboration with related groups such as Fair Work and PHASS would be encouraged.

The evidence and data required to give a rounded and comprehensive overview would come from a range of stakeholders across Government and beyond, including Fair Work, Economy, NHS, Health and Safety Executive (HSE), Chartered Institute for Personnel and Development (CIPD), employers, trades unions and academic institutions.

Target Audience

Scottish Government and stakeholders with a role in delivering Fair and Healthy Work.

Stakeholders

HSE, Public Health Scotland, Scottish Government Health, Fair Work Employment and Skills, and Economy, Occupational Health, CIPD, employers, trades unions, third sector organisations and academia.

Cost

Relatively low as the expertise already exists, though it may be necessary to cover costs for some participants to enable attendance.

Complexity

Relatively straightforward in that this can largely be achieved by bringing together expertise that already exists. In terms of bringing together health related data, the establishment of Public Health Scotland can be expected to bring significant benefits in this respect.

Impact

Essential to setting strategy and monitoring the effectiveness of implementation.

Recommendation 4.7

Stakeholders are fully engaged in the on-going development of the agenda and the refinement and implementation of actions.

Implementation

• Engage with all key stakeholders, in particular employers and unions, to obtain buy-in in to the strategy as it is taken forward, including in the refinement and detailed implementation of possible options.

Evidence/Rationale

Delivering Fair and Healthy Work in Scotland requires the active commitment of a range of stakeholders including Scottish, UK and local government, employers, trades unions, professional bodies, academics and the third sector. The Review sought to be inclusive of these stakeholders in developing its proposals, and refinement and implementation of them will only be possible with their active engagement.

The Health and Work Review Advisory Board brought together a group of people with a wealth of expertise in the field and who represented these key stakeholder bodies, and could provide the basis of the engagement required going forward.

Target Audience

Scottish, UK and local government, employers, trades unions, health and other relevant professional bodies, academics and the third sector.

Stakeholders

Scottish, UK and local government, employers, trades unions, health and other relevant professional bodies, academics and the third sector.

Cost

Minimal, though consideration should be given to covering costs, including for locum/replacement cover, to encourage the participation of clinical staff, employers and third sector organisation in particular.

Complexity

Relatively straightforward, though to ensure participation it is critical to be able to assure stakeholders that their views are important and that they will be listened to

Impact

The engagement of stakeholders is essential to effective design and implementation.