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In some industrial countries, the provision of an occupational health service is regarded as an important part of the Welfare State. In Italy, for example, the prevention of accidents and ill health at work is one of the functions of the local health authorities. Though the NHS has in the past been seen primarily as a treatment service, preventive medicine has gained in importance, especially as soaring costs have placed intolerable strains on the Exchequer. The policy documents and strategies already discussed in this chapter demonstrate the new commitment to disease prevention and health promotion.

Facilities for the treatment of non‐emergency conditions at the workplace can with justification be charged to the employer. He may be willing to pay a dentist, nurse, physiotherapist or counsellor to treat his workers at the factory, especially when there is a long waiting list for NHS treatment. But what of the preventive aspect of occupational medicine? The state provides the Employment Medical Advisory Service, but the numbers of personnel are too small to be able to do more than lead and advise. Where statutory regulations oblige the employer to monitor the health of their workers, they are compelled by law to pay the fees of an Appointed Doctor. The small employer will find it difficult to do much more than this, but there is evidence that employees in such enterprises are at greater risk than those in larger organisations. If the provision of an OH service for every employee is to be a practical possibility, either it must be taken over by the NHS or more cost‐effective methods must be found.

The Gregson Committee was not enthusiastic about an NHS takeover, principally because it found that the health service did not yet succeed in caring adequately for its own personnel, let alone anyone else’s. Since the publication of the first edition of this book, NHS Trusts have improved their occupational health services, but a report of the National Audit Office in 2003 and the Boorman Review of 2009 described the provision of OH within the NHS as ‘patchy’. NHS Plus was a network of occupational health services based in NHS hospitals. The network provided an OH service to NHS staff, and also sold its services to the private sector. It also provided a popular helpline that was transferred to the Fit for Work service. NHS Plus was abolished and replaced by the NHS Health at Work Network. There are over 90 providers around the country offering a wide range of services to outside organisations. This is not part of free statutory NHS provision. The equivalent organisation in Scotland was Safe and Healthy Working (SAHW), now Healthy Working Lives, but its remit is wider than NHS Plus, since it gives all kinds of health and safety advice via NHS occupational health and safety services. It is also free and offers free workplace visits by a generalist health and safety practitioner.

The inevitable answer to the expansion of occupational health service provision is to persuade the employer to pay for it or impose a legal duty. Both France and the Netherlands, for example, impose a legal duty on employers to appoint occupational physicians who are closely involved in monitoring fitness for work and the management of sickness absence. Employers need to be persuaded of the cost effectiveness of OH services.

The HSE published two books in 1993 and 1997, under the title The costs of accidents at work, designed to show that ‘there is no contradiction between health and safety and profitability’. The Health and Safety Executive’s statistics demonstrate the costs to Britain of accidents and ill health at work. In 2018 there were 1.4 million cases of work‐related ill‐health involving an annual cost of new cases of £9.7 billion, excluding long latency diseases like cancer. There were 144 cases of fatal injury and 0.6 million non‐fatal injuries to workers, an annual cost of workplace injury of £5.2 billion. There were 30.7 million working days lost. Total costs fell by approximately 17 per cent between 2004/05 and 2009/10, driven by a reduction in the number of workplace injuries, probably due to the decline of heavy industry, but since then have remain broadly level.

Employers need to be shown how their business could benefit financially if they provide health and safety and occupational health services in the workplace. In 1989 the HSE listed the benefits of providing an occupational health service.

The benefits of providing an occupational health service

 compliance with legal responsibilities;

 reduced labour turnover and increased efficiency;

 less sickness absence and fewer compensation claims through detection of health hazards and adoption of preventive measures;

 less waste of employees’ work time through provision of on‐site first aid and treatment facilities;

 improved general health through introduction of health promotion and education programmes;

 a better motivated workforce and higher calibre job applicants through showing that the employer cares about the health of its workers.

The HSE’s guide Successful Health and Safety Management (1997) included five case studies. An important common denominator is the adoption of a total loss control approach which seeks to identify and eliminate risks, whether or not they lead to injury. For example, a patch of leaking oil could lead to slipping, a fire, breakdown of the machinery, or may have no adverse consequences. If patches of oil are eliminated, then there will be no risk, and no loss. One case study concerned a construction site where the costs of accidents amounted to 8.5 per cent of tender price. Many costs were uninsured, including legal costs, expenditure on emergency supplies, overtime working and temporary labour, and loss of expertise and experience.

The majority of accidents and incidents are not caused by careless workers but by failures in control (either within the organisation or within the particular job) which are the responsibility of management.

The guidance was updated as Managing for health and safety in 2013.

Most employed people work for employers whose workforce is too small for a comprehensive in‐house occupational health service. Research from the DWP in 2011 suggested that only 13 per cent of employers reported providing access to occupational health services. But the specific needs of SMEs can be met in a number of ways. A qualified occupational health nurse can be employed full‐time or part‐time, a part‐time visiting doctor may be appointed, the safety officers can have a key role in introducing and monitoring measures to control the working environment and in checking on their adequacy and effectiveness. Some firms become members of a group occupational health service which provides occupational health facilities on a shared basis to a number of local firms. Some large organisations with comprehensive in‐house services are prepared to offer facilities to small local firms, and the local NHS Trust may contract out services. Increasingly, occupational health services are provided by commercial companies operating on a consultancy basis, including private health insurers like Nuffield Health.

These services are demonstrably cost‐effective. Several examples were given by the Health and Safety Executive. The first is an organisation requiring a high level of employee fitness which has a dispersed workforce of some 2500 people based at 26 sites, some of which are 30 miles or more from headquarters. Medical surveillance is carried out at headquarters by a part‐time medical adviser, costing the employer both overtime payments and travelling expenses. The employment of a nurse to visit all the sites and refer to headquarters only those employees who have to see the medical adviser is more than compensated by reductions in overtime and travelling expenses for the workers. A second example is a chemical company employing over 1000 people and concerned about absence from work due to muscle and joint disorders. It arranges for a self‐employed physiotherapist to attend three mornings a week. The employer benefits greatly from the reduction in absences from work from sickness and attending for treatment outside the workplace. Easy access to the physiotherapy service also assists early treatment which is often essential to a good outcome. Finally, a company using isocyanates requires health surveillance of the workforce. EMAS advises the company to contact a local GP. The GP notices other occupational health problems, such as skin conditions and stress‐related symptoms. This leads to regular workplace visits which improve the health status of the workforce and benefit manager/worker relationships.

The HSE has published information about the tax and National Insurance treatment of occupational health support. An employer is able to claim a deduction against business profits in providing health‐related benefits to employees, provided the expenditure is wholly and exclusively for the purpose of the business. The benefit of private medical care provided free or cheaply by employers to employees is subject to tax on the employee, though £500 of care per annum recommended by occupational health is now tax free. However, the following benefits are not subject to income tax: medical and other treatment for the consequences of work‐related accidents or ill health, health screening and check‐ups, welfare counselling, equipment and services for disabled workers, employee‐only recreational and sporting facilities. This is as long as the benefits are provided by the employer directly to the employee. If the employee is given money to pay for the benefits he will have to pay income tax.

In 2017 the Society of Occupational Medicine (SOM) published Occupational Health: the value proposition by Dr Paul Nicholson. The SOM report is divided into sections: making the business case, the legal, moral, business and financial imperatives for investing in occupational health, the evidence for investing in occupational safety and health and workplace promotion, and finally the evidence for investing in occupational health services. Nicholson states that legal, financial and moral reasons and reputational risk are the key drivers for employers to invest in healthy workplaces and occupational health and safety. He highlights the burden of sickness absence. Minor illnesses are the commonest reason for absence, but the greatest number of days’ absence is due to musculoskeletal and mental health problems. One employer survey reported that sickness absence was estimated to cost UK business £28.8 billion a year. In addition, long‐term sickness absence is a huge cost to the state in welfare benefits.