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Working for a healthier tomorrow
  1. Carel T J Hulshof
  1. Carel T J Hulshof, Academic Medical Center, Coronel Institute of Occupational Health, Amsterdam; c.t.hulshof{at}

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“As a cure for worrying, work is better than whiskey” (Thomas A. Edison, 1847–1931).

Work, matched to one’s knowledge and skills and undertaken in a safe, healthy and supportive environment, can reverse the harmful effects of prolonged sickness absence or long-term unemployment, and promote health, well-being and prosperity. In spite of this, over 170 million working days were lost to illness in the UK in 2006 and around 7% of the working-age population are workless and receiving incapacity benefits. This waste of human potential represents a significant economical and societal cost, and impedes the prospects of many young people, the working-age population of tomorrow. Government, employers and trade unions, healthcare workers and the voluntary sector should unite to help people enter, stay in or return to work by prevention of illness and promotion of health and well-being, early intervention in case of sickness absence, and an improvement in the health of those out of work.

This is the main message of the important report “Working for a healthier tomorrow”, which reviews the health of Britain’s working-age population.1 With a stream of publicity and accompanying activities, this report was presented by the author, Professor Dame Carol Black, National Director for Health and Work, to the Secretaries of State for Health and for Work and Pensions in March 2008. The report, supported by 260 responses to a Call for Evidence and supplemented by six discussion events around the UK, is underpinned with commissioned reviews of the evidence of mental health and work, early intervention in sickness absence, and the business case for employers to invest in wellness programmes for their staff. The sense of urgency is reflected in a “healthcare professionals’ consensus statement” in which more than 30 of the most important health professional bodies in the UK pledge to help people acquire a job or return to their work.

The need for a “wind of change” is articulated loud and clear. A key issue in the report is Black’s appeal for changing perceptions of fitness for work. Instead of sticking to the idea that one cannot work unless 100% fit she recommends that a campaign should be launched to make employers, healthcare professionals and the general public aware that work is in general good for health. This appeal in itself is not new. The evidence base for this is growing. From recent research we know that in particular for the two most prevalent causes of sickness absence or disability in the developed countries, common mental health problems and musculoskeletal disorders, early return-to-work interventions have been successful. Randomised controlled studies showed that work-related interventions were (cost-)effective in reducing long-term sickness absence in case of depression, adjustment disorders/burnout, and back pain.24 Also in more severe health conditions, return to work is becoming more widely accepted as an important outcome parameter of treatment. A study on quality of life in breast cancer survivors revealed that for them employment was important; working provided a sense of normalcy and helped overcome the negative effects of treatment.5 The healthy work message in the report is not new, but the comprehensiveness of the suggested national approach and the asked commitment surely is.

The new approach to health and work in Britain, laid out in the report, is outlined in a number of key challenges and recommendations. Government should work together with employers and representative bodies in order to promote the investment in health and well-being. GPs should change their paper-based sick notes for sick-listed patients in “electronic fit notes” indicating what a patient still can do. Early interventions in sickness absence could be coordinated by new “Fit for Work services” based on case-managed multidisciplinary support. An expanded role for occupational health and vocational rehabilitation is needed, integrated into the NHS and supported by a sound academic base.

Most of the recommendations are fairly concrete while others have to be discussed or elaborated further. Of course, in such a broad and ambitious report, some of the analyses and proposals may be contested or questioned. The expectation that employers will be more willing to invest in the health and well-being of their employees by merely presenting evidence from the business case on the benefits is rather optimistic. A lack of information seems to me not the only barrier to overcome here. Experiences in the Netherlands showed that in particular new legislation that enforced, also by imposing fines, employers, employees, and occupational health professionals to take more responsibility in the management of sickness absence, contributed to a significant decrease in sickness absence and disability.6 To alter the “sick certificate on demand system”7 of British GPs, a profound organisational, educational, and cultural change will be necessary. GPs often act as the patients’ advocate. The bottom line should be that it is in the benefit of their patients to go back to work. Replacement of the sick note is only one step in this change.

Occupational health services (OHSs) are at this moment in the UK available to only a small part of the working population, but instead of putting so much effort in the establishment of new Fit for Work services would it not be more effective, and perhaps easier, to focus on a structural increase in coverage of multidisciplinary OHSs? In case of small and medium-sized companies, such OHSs could be organised on branch level. Several European countries have positive experiences with this. Occupational health professionals should broaden their scope, work with new partners in healthcare, and develop clear standards of practice. Inclusion of occupational health and vocational rehabilitation into the NHS may be an inevitable step but will cost considerable time. In the meantime, part of the gap between general healthcare and occupational health may be bridged by integration of work and health issues and guidance on return-to-work interventions in relevant multidisciplinary clinical guidelines. To be eligible for funding of clinical guideline development, the Dutch Ministry of Health has included in its latest programme the introduction of work-related aspects as an obligatory requirement, stressing the importance of work and health. A guidance document for this was recently developed.8 In addition to Black’s report and the published healthcare professionals’ consensus statement, such a policy may also be fruitful in the UK, for example, in a joint effort by the Occupational Health Clinical Effectiveness Unit and the National Institute of Clinical Evidence.

Notwithstanding these comments, Dame Carol Black’s report is of paramount importance for setting the agenda in the field of health and work in Britain in the forthcoming years, bringing along great opportunities and challenges for occupational health. Supporting the ability to work is the undisputed key issue. We must, however, not forget that in certain situations, despite all of our activities, return to work may not be feasible. In such a situation, taking care of a supplementary benefit would also be part of “working for a healthier tomorrow”. We don’t need a business case for that. It is a matter of civilisation. Work may be superior but sometimes a little whiskey still can do.



  • Competing interests: None declared.

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