Prevention beats cure, says England’s chief medical officer

Efforts to improve health in the workplace over the past few decades have had mixed results. There has been substantial improvement on safety and a more limited one in making workplaces suitable for disabled staff. But there has been slow progress on using the workplace to improve health.

The most direct causes of ill health at work are industrial accidents and occupational diseases. These are on a rapid downward trend: figures from the UK Health and Safety Executive show deaths from accidents have fallen by about 75 per cent since the 1980s and 85 per cent since the 1970s. The UK rate of fatal injuries is less than half the EU average.

The 147 workers and 92 members of the public killed in industrial accidents in the UK in the past year are 239 deaths too many, but thousands used to die every year within living memory. Self-reported and employer-reported non-fatal accidents and injuries have gone down by around half since 2000.

This improvement has been led by changing types of employment; a gradual tightening of the law backed up by inspection; work by the third sector, including the Royal Society for the Prevention of Accidents in the UK; and better science-led industrial design.

There has also been a dramatic fall in occupational illnesses. These used to be common in agricultural and industrial processes, ranging from anthrax in wool workers to pneumoconiosis (coalminer’s lung) and other lung diseases caused by dust. The last major occupational disease in the UK is mesothelioma, from exposure to asbestos. The UK was too slow to address the problem, but the epidemic has peaked and will decline over the next few decades.

Occupational diseases will never be eradicated from the workplace, but they are a shadow of their former significance. Again, the combination of science-led industrial practices and legislation has led to a transformation.

The picture is more mixed when it comes to making it possible for people to work or return to work with a disability or following illness. Work is one of the best things for physical and mental health. Legal obligations, backed up by better design, from desks to hearing aids, have made it possible for many more people with disabilities to work effectively or return to work after illness following reasonable adjustments to their duties.

Two groups remain a concern, however: those who have been unable to work for a prolonged period because of ill-health, and those with variable illness where patients veer between being in remission and relapsing. The data on prolonged absence from work because of illness is stark: once people have been off work for more than two weeks, the chance of returning falls sharply. People with relapsing-remitting conditions — including physical diseases such as multiple sclerosis, or mental health conditions such as bipolar disorders — are treated as more complex to plan work around. They may be exceptional workers most of the time but have unpredictable periods when they have to operate below their normal capacity, or take time off work altogether.

Organisations, including ones in the public sector, that cope reasonably well with people with fixed disabilities, part-time or flexible working and job-shares, often find it difficult to accommodate people with variable conditions.

The area with the greatest opportunity for substantial improvement is using the workplace to maintain and enhance health. Many people spend 40 or more years in work. Modest improvements over that length of time can have a substantial impact on the probability of remaining healthy (and productive) during later working life and well into retirement.

Employers often have high aspirations or at least a strong rhetorical commitment to enhancing the health of their workers. Many schemes, however, have a limited evidence base showing that they work. Some work as planned, others have a more modest impact than intended, and some are probably pointless.

Most organisations and companies that are very systematic and evidence-led about efficiency, productivity and return on investment are unsystematic in their approach to health improvement. This is a shame, because the opportunities are considerable. It should be relatively straightforward to test different approaches. Health gains are largely measurable, and methods such as randomised controlled trials allow us to test rigorously which interventions work.

If we can take the same scientific approach to testing interventions to promote health at work as we have to reducing injury, occupational diseases and exclusion of people with disability, this could be a key area for advances over the next decade.