"Too many health and safety practitioners are afraid of the health side of things," says Professor Sayeed Khan. "They are more comfortable with interlocking and the fire regs."
The EEF manufacturing body's chief medical adviser, a chartered IOSH member, believes that OSH professionals owe it to their organisations to overcome any reluctance to tackle occupational health (OH) and wellbeing issues. (He prefers to use the term workplace health rather than occupational health. "It is about more than just service provision," he says.)
At the operational level there is no reason they shouldn't take on basic non-clinical fitness-for-work assessments in organisations which have no in-house OH provision, he says. "It's about asking an individual 'can you walk all right?' That's a functional issue. If they say no, they'd be better in a sit-down role."
At a slightly higher level, OSH practitioners should have a bigger hand in stress management: "What are health and safety practitioners good at? Risk assessment. That's why some of the stress assessment needs to be done by health and safety practitioners rather than HR."
Higher still, he says OSH practitioners should be driving the growing wellbeing agenda.
"They will know what works best in their environments to promote health and fitness. If you were health, safety and environment director of a company you might say -- perhaps with the HR director -- 'this is the most cost-effective way of improving our wellbeing: early intervention BUPA or subsidised healthy food in the canteen'."
It is no surprise that Khan uses our interview to exhort IOSH members to greater efforts in managing workplace health. He has spent the past 14 years trying to convey the same message to the manufacturers that make up the EEF's membership and lobbying government for more support for business on the issue.
He says practitioners can have a role in driving earlier interventions than even the four to six weeks recommended by the guidance set out by the National Institute for Health and Care Excellence (NICE).
"NICE couldn't say anything because they didn't have the evidence, but my own experience is the earlier the better. Intervene earlier and invest earlier."
My view is you cannot be a health and safety practitioner unless you are a chartered member of IOSH
Investing early means realising that an ageing workforce brings an increase in musculoskeletal disorders (MSDs) and paying for ergonomic assessments to stop problems developing and onsite physiotherapy once they do, he says.
He realises most OSH professionals will probably never wholeheartedly embrace workplace health but he takes comfort from the fact that the biggest group of students on the MSc in workplace health and wellbeing he helped develop at Nottingham University -- where he is honorary professor in occupational health -- are safety and health practitioners.
Sayeed Khan career history
2002--present: Chief medical adviser, EEF 1996--2002: Head of occupational health, Rolls-Royce Defence and Energy divisions 1992--1996: Medical officer, Rolls-Royce Aerospace, Derby 1988-1992: General practitioner
While we are on the subject of the responsibilities of safety and health practitioners, Khan says: "The day when people could say 'I've done my course' in any of our specialties, is over. What I needed to know ten years ago is not the same as what I need to know now. The same is true for safety practitioners.
"The mindset of us as professionals has to change. The days when you got your degree and never did another day's study until you retired are gone and you are dangerous if you have that mindset.
"Nobody's workplace is the same as it was. There have been regulations and changes that are clearly going to change the way you work."
Isn't that the purpose of continuing professional development (CPD) requirements? He sighs. "Well, I think CPD is the first step but even as doctors, and I am guilty of this, we sit through a course and tick a box as opposed to verifying what we learned from it."
In the scheme of things
Sayeed Khan is the chief medical adviser to the EEF, reporting directly to the chief executive, former Health and Safety Executive (HSE) chair Dame Judith Hackitt. He provides expert advice and guidance on workplace health issues and strategy to the EEF, gathers data on health trends and lobbies the government on better workplace health provision on behalf of the 6,000 manufacturing businesses that make up the organisation's membership. He says this part of the role is particularly important for the small firms. "The big guys have always had a voice, sitting on committees and so on, but 76% of the EEF membership is SMEs ."
No one reports to him at the body "because there is no one else in occupational health" at EEF.
He is also chief medical officer at OH services provider Collingwood Health, formerly EEF Occupational Health Services, and is partly based in its Slough clinic where he still gives advice on complex cases. He chairs the company's clinical governance board, which ensures consistency of provision in the screening, surveillance and treatment it offers. "We stopped some practices that were not useful that had arisen by custom and practice in medicals that were not useful and introduced others," he says. He gives the example of measuring body mass index: "Ten years ago that wasn't such an issue. But you have to now be aware of the weight limit for office furniture, for forklift trucks and for paramedic services to be able, reasonably safely, to get someone down from a crane. We've started having people exceed those limits."
Doctors now have to revalidate their competence or they are no longer allowed to practice, but there is no equivalent for OSH practitioners.
"Once you have a revalidation requirement people start paying attention to their CPD," he argues.
He says revalidation should be a reassessment of fitness for chartered membership, rather than retaking an academic qualification: "My view is you cannot be a health and safety practitioner unless you are a chartered member of IOSH."
When advising employers on health and safety provision at EEF, he has always argued they should recruit only CMIOSH practitioners, just as he now advises them to take on OH services that are accredited to the Safe Effective Quality Occupational Health Service standard.
He concedes the concept of revalidation becomes feasible only once a majority of IOSH members achieve chartered status.
Called to serve
After qualifying as a doctor in 1988, Khan treated patients in general practice in Nottingham for four years before being lured by OH: "I had done a bit of occupational health for a small brick company, and I realised I enjoyed my one session there a fortnight more than my nine sessions of general practice."
He gained more experience providing health support to meat pie producer Pork Farms, Northern Foods and Nissan.
"It was a challenge dealing with people in an environment where the white coat didn't rule. In the NHS [National Health Service] everything is on the terms of the provider. On the shop floor it's on the terms of the employer, the employee and the unions.
"You can't come into occupational health green," he says. "You just get eaten up. You need some experience in the general foundation of medicine or nursing, because it's not just about clinical skills and negotiating skills."
He moved to Rolls-Royce in 1992, initially as medical officer at the aerospace plant in Derby, graduating to head of OH for the engineering group's defence and energy businesses.
He says his time there taught him "what a benchmark OH service could look like if you have the resources". It allowed him to test his belief that rapid interventions, such as physiotherapy in the first 48 hours after a condition is reported, repays an employer's investment.
(Now, he says, he would struggle to name a benchmark OH service in industry because so many companies, including Rolls-Royce, have contracted out their provision.)
He joined the EEF in 2002 in the new post of chief medical adviser (see box on p 53). "Martin Temple, then chief executive, thought we weren't doing enough on workplace health and the only way to do that was to have somebody appointed to look specifically at it."
It remains an unusual job, he observes; there is no equivalent position at the Confederation of British Industry, the Trades Union Congress or the NHS.
Khan's time promoting workplace health to business and government contributed to and coincided with a growing realisation in government that there were multiple benefits to the public purse from stopping sick employees falling out of the workforce for long periods, or altogether.
Four years after his appointment, the Labour administration selected Dame Carol Black as the first national director for health and work; Khan was on the panel that interviewed her for the job. He was then appointed to the Health, Work and Wellbeing Strategy National Stakeholders Council, which advised on and helped promote the strategy recommended by Black for improving the health of the working population.
He was then involved in some of the groups that supported the main planks of the strategy, such as NICE's Programme Development Group, which produced guidance on managing long-term sickness absence, the government's Sick Note Review Stakeholder Group and the Royal College of General Practitioners' National Education Programme in Health and Work for GPs.
For six years during this period he also served on the governing board of the Health and Safety Executive (HSE). More recently, he was appointed to the government's Industrial Injuries Advisory Council (IIAC).
Though his role at EEF and time served on these other bodies might have been expected to eat all the available hours, he has always maintained some direct clinical practice, holding OH clinics at a food manufacturer's sites in Gloucester and South Wales.
As biological entities we cycle in our moods all the time. So being happy all the time is unattainable
"I've always done at least a clinic a month," he says. "It gives you street cred. There are very few people in senior occupational health positions who actually get their stethoscopes out. It also has kept my clinical skills up. It's not like riding a bike; you soon lose it."
In 2011 Khan chaired a government working group advising on the direction of health, work and wellbeing policy over the following five years.
"What we suggested was that we didn't need any new initiatives," he says, "that we should consolidate what we had."
A main strand of government policy was OH support for small businesses in the form of the Fit for Work Service. Finally launched in 2015, it allows employers and GPs to refer individuals absent from work to a government-funded assessment and advice service designed to aid an accelerated return.
He is clearly unimpressed with the service's reach to date, describing it as a "toe in the water". "They haven't got anywhere enough clients to see," he says of the advisers.
He flagged up the need to engage GPs with the scheme from the start but that has never happened; the scheme's contractor, HML, "just did not do enough. We have nowhere enough GPs aware of the service to pass it on."
The scheme will not fail, he says, but it may never generate enough data from numbers returning to work earlier after sickness to be sure whether the programme justifies the effort that went into it.
However, the service's marketing to employers may have had some benefit in raising awareness about OH issues among micro-businesses.
A bum note?
The fitnote, which in 2010 replaced the old MED3 sicknote issued by GPs to patients too sick to work, was another development the government working group flagged as needing consolidation -- and another one which has yet to deliver on its promise, he believes. He says the evidence is that GPs' use of the options on the fitnote to sign employees fit to work with adjusted duties is diminishing. (The EEF's latest sickness absence survey found that only 13% of employers believed the note had hastened sick employees' return to work, down from 24% in 2010.)
As with the Fit for Work service, he believes the commitment of doctors is critical to improvement.
"It's because they are not being incentivised," he says. "In fact they face a disincentive. GPs have highlighted in our training how difficult it is not to give a note to someone if they want it -- it's bullying [by] patients."
One option that could have helped make the fitnote succeed would have been mandatory training for GPs. The 4,000 who received face-to-face training plus a further 10,000 who went through an e-learning course left 80% of GPs without detailed instruction in using the new MED3 form.
"You could make it mandatory for the Royal College [of GPs] to say 'you must have training in this'. The principle is simple: what can [the patient] do? Yes, they can do a sit-down job. That's your job done, Mr GP. If the employer can't find anything like that the patient stays off. That was the ethos, but it hasn't gone that way."
Another option would be to train one GP in medical practice so they would be referred each case that called for a judgment on fitness for work.
Or employers could disregard the fitnote altogether and arrange their own occupational assessments, "which is what the big organisations pretty much do anyway".
Another public policy recommendation of his 2011 working group, yet to see fruition, was to make returning patients to productive lives an objective for the NHS. "Everything in the NHS is target-driven," he says. "I'm not saying the target has to be paid work -- it could be becoming a carer again or working in a charity shop, but being an engaged part of the community. Until you have that as an outcome, you are just taking people out of the hospital and they are sick at home and not getting the care they need to get better."
He says individual value to society has not been factored into cost-benefit analyses by the NHS funding overseers such as NICE -- though there are signs this might change -- so patients on lower-level, cheaper maintenance medications for conditions such as rheumatoid arthritis might still be incapacitated to the point where they lose their jobs.
"Whereas the clinician seeing that person could be thinking 'Are you in work? Are you having problems working? All right, we are going to get you on to the next level to keep you at work'."
Orders of magnitude
Workplace health management starts with preventing the "big five" conditions that are traceable to work, says Khan: hearing loss, vibration disorders, respiratory diseases, skin conditions and occupational cancers.
"We still have a problem with the big five, 40 years after the Health and Safety at Work Act. We got better with noise and vibration and then skin disorders, but it's only recently with the work of [researcher] Lesley Rushton that we have started to take proper notice of occupational cancers."
But measured in terms of their impact on productivity, the second-tier conditions, such as mental health problems and MSDs are far more serious for industry, he notes. Employers can also tackle these by improving the working environment and following guidance such as the HSE's Stress Management Standards. But focusing on work-related stressors or workstation assessments and manual handling aids only tackles part of the problem.
For that reason Khan welcomes the growing realisation by employers that they gain from helping employees thrive outside the workplace and from "keeping the well well".
Supporting employees through fitness programmes and mental resilience training is not a soft option, he says, but a necessary adjustment by employers to the ageing society and high levels of stress-related absence.
People with mental health conditions are a small proportion of the workforce and need treatment similar to that for their peers with chronic physical conditions to help them keep working, he says.
But he identifies another category, the "worried well", as a cause for concern. "[These are] people who for whatever reason believe they must be happy all the time. That's not a reasonable construct, but it's what society or the media is telling them, that if you are not happy there is something wrong with you.
"No, there isn't. As biological entities we cycle in our moods all the time. So being happy all the time is unattainable."
Trying to achieve such an impossible end just makes people even more unhappy and stressed, he says, "as opposed to saying 'there will be good days and bad days' and just getting on with it."
He suggests doctors might be compounding the problem. In general medical practice, he says, attitudes towards mental health have shifted positively over the past 25 years, "perhaps a bit too far."
To know that over the years, more than 50% of employees never have a day off work on average, is fabulous
In his years as a GP at the turn of the 1990s, no doctor he knew ever wrote a sicknote for stress. "Then in the 1990s we moved into sicknotes for patients who were 'tired all the time'. We still didn't call it stress, that came in in the late 1990s and early 2000s."
The most recent development is for GPs to state work-related stress as a reason for signing off patients.
"From the GP's point of view, the patient has said 'work is causing my problems'," he says, "so they write down 'work-related stress', but that's one side of the story."
I ask him whether he thinks any part of the growth in stress-related absence is due to individuals' expectations that work should be stress-free, like the mistaken expectation of happiness he described earlier.
"There is a small percentage of people who are stressed because they are incompetent," he says. "They are stressed because they can't do the job. There is a larger proportion who can do the job but it has changed and they need to look at how that makes them stressed. There is an equally large proportion of people who are blaming their work for the stress when it's actually other things in their life they can't change."
He breaks his flow to say that he doesn't want his points about bullying patients and people blaming general stresses on work to give the impression that he does not respect the dedication of most workers.
"One thing I've found is how good a work ethos we have," he says. He notes that the EEF annual absence survey asks employers about presence levels, with salutary results. "To know that over the years, more than 50% of employees never have a day off work on average, is fabulous.
"If you added the others who have one or two days off, that's the vast majority of the workforce taking little or no time off. We aren't the sick man of Europe, we have diligent workers. But there is a small minority who play the system and they do it with GPs."
He praises the many people who work while managing chronic conditions such as diabetes or asthma. He is a case in point; he has rheumatoid arthritis: "The consequence is that I don't start early in the day and I don't do as many long drives in the day."
Such conditions shouldn't be a barrier to employment with the right medical treatment, providing businesses adopt a flexible stance when they can. "You can't change the speed of a production line," he concedes, "so someone has to look for a different job if they can't work at that pace."
There are few jobs that are so rigid, he says. "But you get many employers who say 'we can't possibly alter that'. When you ask why not, they say 'we have always done it like that,' which is not the right answer."
Employers and government will need increasingly to adjust to another growing phenomenon, he says, one that is seldom discussed in the workplace context, that of workers with caring responsibilities for ageing relatives: "Institutional care is so expensive and we are losing people from the workforce as they become carers. And they become benefit recipients instead of taxpayers."
"Flexibility will have to become the norm," he says. "There has to be a change of mindset in manufacturing and services." With 24-hour operation and continuous production, the day of nine-to-five working will soon be gone, he argues.
I wonder if this idea of mix-and-match patterns conflicts with the increasing body of research that associates some non-standard working patterns with higher cancer rates and incidences of other diseases.
"We aren't supposed to shiftwork," he says, "particularly rotating shifts, but the problem is we have created a 24/7 society for a lot of things. And some of it is not choice. Healthcare and the police, they have to be 24/7."
Instead, intelligent work rostering is needed. "We still have crappy shift patterns that are good for production or service provision but not good for the human being. We have to change it around. And the push might come from employees saying we need to work flexibly."
"Nobody wants to touch shiftwork," he says of the health establishment. The IIAC, on which Khan sits and which classifies industrial diseases that qualify for compensation, considered prescribing breast cancer linked to long-term shiftwork but needed evidence that the risk was doubled. Nevertheless, "there is definitely something there," he says.
He says the HSE needs to take the lead on some of these issues it has shied away from in the past, such as shiftworking or chronic MSDs.
The subject of leadership and influencing skills is clearly one he has thought about. I ask whether good leaders are made by nature or nurture. "It's a combination of both. Your experiential knowledge is a stronger element than I ever thought was the case. Because I've realised how many mistakes I've made and learned from them."
Younger people promoted to senior positions have it hard because of that lack of experience: "They might be intellectually bright but they don't have the gravitas."
"A good leader is visible every day," he adds. "Being in a London HQ, never being seen, isn't good leadership." Similarly, he recommends keeping the circle of communication as wide as possible, "talking to the cleaners and the receptionists who are the founts of all knowledge. A good leader knows who knows what."
Humility is another important quality: "A good leader knows when to say sorry and how to say it, particularly in my environment because one of the biggest complaints about healthcare professionals is they never apologise."
Finally, he says, the best leaders have the emotional intelligence to think carefully how to sell their messages. "They always answer the question 'What's in it for me?' Whether it's the [benefit of the] organisation or the employee or the manager."