the Black Report stressed. Unfortunately, the number of institutions engaging in OH research has declined in recent years. University departments have closed. The Health and Work Development Unit (HWDU), a partnership between the Royal College of Physicians and the Faculty of Occupational Medicine, was closed in 2014 when funding was withdrawn after seven years. The Unit, led by Dr Sian Williams, was responsible for the creation of several important clinical guidelines relevant to health and work. In 2019 the Society of Occupational Medicine published a report: The Value of Occupational Health Research: history, evolution and the way forward, co‐authored by Professor Ewan MacDonald of the University of Glasgow. It called for the creation of a national Centre for Work and Health to coordinate UK occupational health research and best practice.
Work as a clinical outcome
The lack of training in occupational medicine for medical, nursing and allied health professionals in the universities has led to a lack of appreciation among clinicians of the effects of health on work and work on health. Clinicians should be informed of what work their patients do and should assess the success or otherwise of clinical interventions partly by whether a patient of working age is able to remain in or return to work. In 2019 a large number of organisations concerned with health care agreed a healthcare professionals’ consensus statement:
Work which is appropriate to an individual’s knowledge, skills and circumstances and undertaken in a safe, healthy and supportive working environment, promotes good physical and mental health, helps to prevent ill‐health and can play an active part in helping people recover from illness. Good work also rewards the individual with a greater sense of self‐worth and has beneficial effects on social functioning … The crucial relationship between work and health dictates that, where appropriate, remaining in or returning to work must be a critical outcome measure for success in the treatment and support of working age people’.
The disability employment gap
Less than half of disabled people are in employment (48 per cent) compared with 80 per cent of the non‐disabled population. 4.6 million disabled people and people with long‐term health conditions are out of work. People who are unemployed have higher rates of mortality and a lower quality of life.
In a Green Paper published in 2016: Improving Lives the Department of Work and Pensions and the Department of Health and Social Care initiated consultation on how to achieve their ambition of halving the disability employment gap. Its wide‐ranging proposals covered health services, welfare provision, and the role of employers, and included the provision of better occupational health support. An important development was the suggestion that models of integrating occupational health within NHS primary and secondary care services provision could be explored, re‐orientating a part of the NHS occupational health workforce to provide patient services directly. ‘Potentially it may also be possible to expand availability of occupational health, at least for people with more complex needs who do not have occupational health provided by their employer, are self‐employed, or are out of work’.
The projected White Paper following the consultation did not appear. Instead, the government published its reply as a policy paper: Improving lives: the future of work, health and disability (2017). It took the opportunity also to reply to Thriving at work: the Stevenson/Farmer Review of mental health and employers (Department for Work and Pensions, 2017) and Good Work: the Taylor Review of Modern Working Practices (Department for Business, Energy and Industrial Strategy, 2017). As regards occupational health, it stated that evidence showed that effective OH provision can help protect and promote employee health and wellbeing, and prevent unnecessary sickness absence long‐term, but that the current model of OH provision did not meet the needs of employers or individuals. An Expert Working Group on occupational health was set up to advise on reform and research was commissioned to understand better the current market supply and delivery structures of OH provision and its operation. The feasibility of integrating OH into primary care pathways was explored, in particular with Greater Manchester Combined Authority and the Scottish Government. In 2019 the Work and Health Unit began discussions on proposals for reform in Health is everyone’s business (above).
1.2 The legal obligations of the employer
The law imposes a number of specific obligations on the employer relating to the health of their workers and, more generally, the Health and Safety at Work Act obliges them to ensure their health and safety so far as is reasonably practicable. As yet, there is no specific duty in our law on the employer to provide qualified medical or nursing staff at the place of work.
The Health and Safety (First Aid) Regulations 1981 oblige employers to provide adequate and appropriate first‐aid equipment and facilities and an appropriate number of adequately qualified and trained persons to render first aid to his employees. The First Aid Approved Code of Practice ceased to have effect in 2013 and was replaced by HSE Guidance which was updated in 2018. Also, in 2013 the requirement that the HSE approve first aid training and qualifications was removed. Employers must assess their first aid requirements appropriate to their particular circumstances and the hazards in their workplace. Adequate facilities and equipment for rendering assistance to workers in the workplace in a case of accident or illness and for summoning an ambulance in an emergency must be provided. They must ensure that, if first aiders are appointed, they are provided with suitable training and have an appropriate first aid qualification which is regularly renewed. Where qualified doctors, nurses or paramedics are employed they can act as first aiders without additional training. In a low risk environment it may be sufficient to provide a first aid box and an appointed person (not necessarily a trained first aider) to take charge in an emergency. The number of employees on the site is a relevant consideration. Employers are not obliged by the First Aid Regulations to make provision for members of the public, although the practice of organisations like schools and places of entertainment in making first aid provision for non‐employees is strongly recommended by the HSE. The employer owes duties under the Health and Safety at Work Act 1974 both to his employees and also to people not employed by him. Employers must inform employees of the arrangements that have been made for first aid in the workplace. First aid does not include giving tablets or medicines to treat illness, except aspirin to someone with a suspected heart attack.
In recent years there has been a move towards putting pressure on employers to provide mental health first aid, though this is as yet not covered by the regulations. Mental health first aider training has become popular and has been supported by several large employers. At time of writing there was little evidence of its effectiveness, other than to help to reduce the stigma of mental illness. Detailed research is needed. This training should be distinguished from the training of managers in sensitivity to workers with stress and mental health problems, and how best to assist them.
As regards legal liability, first aiders owe a duty of care and a duty of confidence to those whom they assist. There is no responsibility in law as a Good Samaritan to go to the help of a stranger, although if assistance is given, reasonable care must be taken. However, first aiders appointed by the employer are not Good Samaritans. They hold themselves out as providing a service for which they are paid and therefore have a duty to assist if called upon; the standard of care expected is that of a reasonably competent trained first aider, not a doctor or nurse. The Compensation Act 2006 provides that when a court is considering a claim for negligence or breach of statutory duty it may consider whether the taking of reasonable steps to meet a standard of care might prevent a desirable activity from being undertaken (Chapter 6). The Social Action, Responsibility and Heroism Act 2015 provides that courts should take into account whether the person being sued acted for the benefit of society or its members in a predominantly responsible way or heroically in an emergency to assist another. No case has so far been recorded of a first aider being held legally liable, but it is advisable that they be covered by the employer’s liability and public liability insurance.
