Dame Carol Black: “The workplace capability assessment has not been a success”
Earlier this month Dame Carol Black – Government advisor, doctor, Principal of Newham College at the University of Cambridge and past President of the Royal College of Physicians- put health firmly on the agenda at the British Safety Council’s annual conference.
Here, she speaks to SHP’s Lauren Applebey about her opinion on why the controversial Work Capability Assessment scheme is failing, the struggles GPs face in writing a proper fit note, getting people back to work after ill health, and how she feels companies should be dealing with mental health at work.
You spoke at the British Safety Council conference about health in the workplace from a business perspective – including looking at studies from the USA about integrating health into workplaces. What do you think the UK can learn from these studies?
We’ve been concentrating very hard on conventional occupational health and safety. Considering what it is about the workplace that can make you ill, and asking if people are fit enough to be in that particular environment, that’s bounded by legislation and regulation.
What we haven’t made an attempt to embrace and – as Glorian Sorensen says – truly integrate, are all of the things about your physical and mental health which affect your ability to be a safe worker. This includes your wellbeing; if you go to work with no sense of wellbeing then you may not be as attentive to the safety requirements.
It is a movement away from the two separate parts of the system – strategists should work together, your deliveries should be together and when you evaluate if you have a safe system, in the conventional sense, are you evaluating the wellbeing? So, that is quite different and we have a long way to go in this country.
What I think they’ve also been trying to do in their programme Safewell at a much more practical level is to help people do that. They are linking safety and wellness and there are tools in there to help you write your policies.
Do you think businesses are beginning to understand their responsibilities for their workers’ health in the same way they understand the dangers of exposing their staff to safety risk?
They are definitely taking it more seriously. Is there a spectrum? Yes, definitely. There are the companies we know have been doing it well for an extremely long time – people like BT, Rolls Royce, and KPMG. I think construction, the railways and the police have, in the last five years, really started to take this seriously.
Of course some companies will have done more than others – and some managers will think it more important than others, but what is much more difficult is for the small companies. The big companies have the capacity to do it, it’s just about whether they have the board engagement and whether the CEOs are willing to do it.
It’s far more difficult if you only have 100 workers; people have to work very hard, and often they don’t have big HR functions, and they may only have occupational health as a part time role. It’s the things they haven’t got compared to the big companies. You could almost say there is no excuse for a big company.
In terms of illnesses and disabilities that might not have been caused as a result of someone’s occupation, but affects someone’s ability to perform their job safely – are employers aware enough of how to support their employees – and not just in work but outside of work too?
No, I think some of the topics are difficult for them to discuss at all. So stress, anxiety and depression – it’s not an easy topic – but there are simple things they can do to support them in work, maybe with mental health first aid or mental health champions, ensuring that people have got some control in their work, because that really affects your mental health.
What some companies have done, and it’s not that difficult to do (for example BT have done it very well) is make it possible for their workers to do a questionnaire online at home on their own mental health and resilience. So you can assess yourself and do it in the privacy of your own home. Then, if you want more help, you can go further into the programme.
I think if you do it well in work, it often spills over into home life. For example, I think if people give up smoking and they come from a household that smokes, or if you’re starting to eat more healthily, you can often take good practice home.
One of your most well-known works within health and safety is the 2008 Working for a Healthier Tomorrow report, which looked at health, work and wellbeing. Eight years on how do you feel things have changed?
That’s a good question! When I wrote the report I thought the easiest bit to make an impression with was the bit from my own profession. I thought that really getting doctors, nurses and physios to understand that you can write not a sick note but a good fit note that informs employers – would be one of the easier things I had to do.
Working with employers, getting them to understand what this was about, even getting the trade unions on side, wasn’t easy in the beginning, as they thought I was all about getting sick people to work – which was absolutely not true.
The third sector has embraced it very well, and government gradually year on year has moved in the right direction. Whichever government it was – Labour Government, the coalition, or the current Government – this agenda has been of increasing importance and there is now the new Health and Work Unit, a cross-government proper unit.
I would say the thing that has disappointed me has been to get my medical colleagues to write a good fit note. We’ve done lots of education – both online and face to face and I think we just have to think about how we do it differently.
We are asking the GP to do something that is anti-pathetical to their relationship to their patient – in their 1-2-1 relationship they think of themselves as the advocate for the patient and they don’t want to say: “You can’t have a sick note.”So, we debated long and hard when I wrote that report and in the Sickness Absence Report about whether GPs were the best people to do this.
In some countries in Europe it is the occupational health professionals that do it, but we don’t have enough of them. If you look in the Netherlands they really have a lots of occupational health medics and nurses, so they can do it differently and I suspect that that is better because it’s not your family doctor, it somebody whose expertise is occupational.
Since the report we have seen the sick note become the fit note, the release of the fit for work service and the controversial Work Capability Assessments (WCA). Do employers, employees and GPs really know where they stand with the process of ill-health at work and the process of returning to work following ill health?
It’s very variable. I think if we could get the health community (and I really would broaden it beyond doctors) to understand that if you have a well-written fit note linked to really early intervention you are more likely to get people off their sick absence and b
ack into work.
If you leave it longer, then they leave the workplace and maybe get in to our benefits system, and then your efforts to bring them back into work have to be much, much greater.
The WCA has not really been a success, I don’t think anyone thinks it has been a success, has been revised four or five times. It has had four reviews – and every time people have tried to make it better, and there’s been genuine attempts to try to improve it. But, if you think about it I think it’s really badly placed.
For example: your doctor or a medically-qualified person has told you for a minimum of 28 weeks, probably more, that you are not fit to work – so you get into your head “I am not fit to work” and then you may not get assessed until you’ve almost been out of work for a year. Then somebody does a computerised assessment and says: “Well, you are fit to work” – I mean, the mismatch!
I think that assessment is really at the wrong place – we did make some suggestions in the Sickness Absence Review and I think Department of Work and Pensions has been taking a very hard look at it.
In terms of mental health, disabilities and invisible illnesses – how can we ensure people are being fairly assessed – especially considering how individual and complex health is person-to -person, and even for the same person, day-to-day?
I think the first thing is that you have to do is separate it out – and I think people do this quite well.
I go to people who have enduring mental health problems, and by that I mean schizophrenia, endogenous depression, manic depressive psychosis, real personality disorders – because that is obviously deeply fluctuating. Sadly, I think it’s only about 8 per cent of those people who are in the workplace and it should be much more.
Then there’s the big mass of people who suffer stress, anxiety, mild depression and I firmly believe that if you improve the management of those people – the atmosphere in which they work, the respect with which the manager treats people, and making sure their voices are heard – you wouldn’t have to be giving them pills and potions. You might want to do one or two sessions of CBT or a bit of counselling – but on the whole those problems will settle if that persons is helped to be in a good workplace.
I think to make it deeply complicated, before that, I think a lot of mental health problems arise from poor management – or inappropriate management.
Health has certainly shifted much further up the agenda, but are we being reactive rather than proactive – and what is the best way employers can move forward from this point with respect to the health of their employees?
I think if an employer wants to be really proactive, as I’ve just said, they need to have teams that really understand about people – so that within any department you can understand if Mrs Smith really isn’t quite herself today. And you may encourage her and offer peer-to-peer support to make it abundantly clear that if you do say you are having trouble or you don’t feel so well, it won’t affect your job promotion and you won’t be stigmatised. What people so fear is that they will be stigmatised.
Personally, what I am very keen to get people to understand is that physical exercise – and I don’t mean running a marathon, but going for a walk at lunchtime – is connected to your mental wellbeing. It’s encouraging and making it easy for people to do the right thing. I think it’s about making people aware that you have a good alcohol policy and that if you do have a problem then again you can go safely somewhere. All the things that make it clear that your boss is there to make your life as reasonable as possible.
And it’s about not putting too many unreadable demands on people, having some flexibility. I think these are all things that good workplaces do and you know a good workplace when you walk into it. I’ve visited enough and you really understand when people are not in a good place.
You were head girl at school, a doctor, the second ever female president at the Royal College of Physicians and are now principal of Newham College, Cambridge (a female only college). Like health and safety you have worked in some very male dominated sectors. What advice would you have for women working in a man’s world?
I remember when I qualified in medicine it was a man’s world. I think it’s slightly harder in construction than it is in medicine, where in a way what you had to do was to get the female students to feel confident enough and to be secure enough in themselves that they’d put themselves up for the same jobs as men.
In the past it would have only been men who are surgeons. If you want to be a surgeon now you should ask yourself if you feel confident enough and bright enough to go for that training? How do you enable women to feel that they are perfectly capable to do these jobs and that they don’t have to do them like a man? I think that is important.
In term of women engineers on site, I hope there are many more of them and I hope they are bringing their own personality to that. I felt it’s quite important to not see men as the enemy – it’s important to work with them.
I think the other thing that women have to find is sponsors. Men have much better networks on the whole and sponsors will just say to Joe Bloggs: “She’s really good.” and if there’s a job opportunity: “Perhaps she could be interviewed.”
It’s about putting you in the right place and at the right time. I think women don’t seek that, but men do. Nothing is as powerful as being highly competent, really feeling that you know this and you can do it as well as anyone – another woman or another man. I think that one of the strongest messages.