NHS Plus has developed a web-based system designed to provide OH teams with an efficient way of maintaining and improving the quality of their services. Nic Paton reports.
Mohawk native Americans were the original New Yorkers, a traditionally fierce people disparaged by their enemies as "man-eaters" or, possibly more respectfully, known as "people of the flint". Why this nugget of American history is appearing in a journal such as Occupational Health is that their name (if not their reputation) has now been appropriated by the NHS as the acronym for its latest web-based occupational health clinical governance system.
The clunkily named Management of Health at Work Knowledge (MOHAWK) system nevertheless has the potential to be a powerful tool for OH practitioners and could even, in time, become a valuable quality assurance template for private and commercial OH providers.
Occupational Health columnist and physician Dr Richard Preece, who helped to develop the system, explains: "It is about helping people to answer the question of 'how do we sit relative to everyone else in terms of particular measures?' It is a benchmarking tool. The public, too, will much better be able to see who is doing what."
MOHAWK is, for the moment at any rate, a tool solely for NHS Plus practitioners and was launched into the NHS in March.
Teams or practitioners input data twice a year into the system and, using five indicator benchmarks of occupational health effectiveness, can then compare their performance with others (see table). Practitioners will also be able to see anonymised data to get a wider picture of how the overall performance of health at work services is improving, as well as share and compare data with their peers.
Just as importantly, the development of MOHAWK starts to put NHS OH practitioners and units on a par with other specialties with similar clinical governance systems, such as renal services and endoscopy.
"If you are a local commissioner of care or an HR or operations director you will be able to gauge much better how a service provider is performing and how they are doing against the national spread. There will, inevitably, be some good and some bad, and there is also likely to be debate about whether our indicators are right," contends Preece.
"But the key is that people are going to be able to start off with evidence and informed indicators. We will also start to see how many thousands or hundreds of thousands of transactions there are. The public will be able to see the graphs, although you will not be able to see individual organisations," he adds.
Of course, the obvious question that springs to mind is: isn't this remarkably similar to the Safe Effective Quality Occupational Health Service (SEQOHS) standards, the occupational health accreditation system being led by the Faculty of Occupational Medicine and the Royal College of Physicians (RCP), which, since its launch, has proved remarkably popular with practitioners?
The MOHAWK system has the potential to be a powerful tool for OH practitioners and could even, in time, become a valuable quality assurance template for private and commercial OH providers."
Preece, for one, makes a strong case for the distinction between the two, arguing that it is complementary rather than competing with both SEQOHS and the RCP's and faculty's Health and Work Development Unit audits.
"It is different from SEQOHS, but similar," says Preece, "SEQOHS is designed to make sure the service provider is complying with a set of basic standards for OH service provision. So it is not a tool designed continually to drive improvement; it is about saying whether someone complies, it is a baseline for compliance. MOHAWK is more about designing something that will improve standards of care.
"You may have all the ingredients in place to deliver a compliant service but may, in fact, not be improving. It is like knowing you have the right ingredients to bake a cake, but is it a good cake?
"We are trying to drive improvement and we are looking at more specific issues around quality in a higher degree of detail. It is also about being able to share performance data between organisations."
This is all well and good, but when Occupational Health tested the water to see what people thought of MOHAWK, it was clear that there was still some ignorance about it among a few NHS practitioners, not to mention a certain degree of scepticism. As one practitioner, who wished to remain anonymous, put it: "I personally don't feel that the MOHAWK product has been effectively promoted or explained, and with such an isolated personal experience, I question the amount of real input from the wider NHS network."
More worryingly, for those looking to promote its existence and value, the practitioner added that they could not think of a single colleague outside their local NHS board who was likely to have a different opinion.
As with anything, and especially anything within the NHS, there is therefore likely to be a bedding down and "getting to know you" process, an element of people needing to become comfortable with, and buy into, the MOHAWK system.
Mandy Murphy, chair of the London Consortium of Occupational Health Practitioners and occupational health service general manager at Guy's and St Thomas' NHS Foundation Trust, concedes: "This is only going to be as good as the information that is put into it. On the other hand, occupational health does not have anything like this at the moment."
She adds: "No one is disputing we need something like this, but the details do need to be discussed. There needs to be a lot of thought around how the data is being presented and interpreted."
To an extent, the development of something such as MOHAWK is a logical progression for the NHS. This is due to the focus on both quality and performance improvement and strengthening the evidence base for occupational health by Dr Steve Boorman's review of NHS health and wellbeing and the various reports by former national director for health and work Dame Carol Black.
We are trying to drive improvement and we are looking at more specific issues around quality in a higher degree of detail. It is also about being able to share performance data between organisations."
Dr Richard Preece,
co-developer of MOHAWK
"I think it is a good step forward; I believe this could be a really useful tool. It will allow practitioners to compare themselves with other departments. For example, if you are processing referrals within two weeks, how, in reality, are you doing? What does that mean, especially if you now find that everyone else is, say, doing it within two days?" argues Dr Ursula Ferriday, consultant occupational health physician at Worcester Acute Hospitals NHS Trust and chair of the NHS Health at Work Network board.
In the past, occupational health has been somewhat disparate and silo driven, but a system such as this will help to encourage more networking and knowledge and metrics management, she contends.
"OH is starting to get very good at collecting data in terms of its own activity and how it compares and contrasts. On its own it has limited value, but if you can align it with overall metrics for the UK, then it becomes much more valuable," explains Ferriday.
"The NHS OH service does not work in isolation and any way of breaking out of silos, perhaps by becoming more open or working more with other specialties, is going to be welcome. It is about trying to move quality standards and OH provision forward as a single entity," she adds.
Driving best practice
"Most occupational health nurses are, frankly, useless at sharing things, but if this makes them share best practice then that is going to be brilliant," says Christina Butterworth, head of health at BG Group and president of the Association of Occupational Health Nurse Practitioners (AOHNP).
She adds: "It will also potentially be a good way of letting people know that occupational health as a profession really rates quality; it will help occupational health to demonstrate that it is a quality-driven profession."
"My concern with SEQOHS, for example, is whether, particularly for bigger providers, you can gain accreditation for the organisation, but it may not be that every nurse is working at the same level. With MOHAWK, it is more about the individual practitioner and so it could be a way of getting around that.
"I believe this system is going to be excellent for OH nurses going forward, especially if it extends beyond the NHS. There could be significant synergies. It potentially gives you an extra tool to make things easier and is just the sort of thing OH nurses are crying out for."
Room for manoeuvre?
Certainly, as Preece points out, the tool has been very much developed with the ambition of one day being able to extend into the commercial and private OH arena.
"It has been developed with an eye firmly on the NHS, but its indicators are not unique to the NHS, nor do we want to restrict it just to the NHS. It is not about saying people are bad, it is about saying how good can you get?" he says.
I believe this system is going to be excellent for OH nurses going forward, especially if it extends beyond the NHS."
That may well be so but, for now at least, the reaction from the private sector appears to be muted at best. First, with the NHS having something of a poor track record when it comes to big-ticket IT projects, there is suspicion about the value of anything that links the words "NHS" and "technology". Second, for the majority of big commercial providers, there is an element of "why should we reinvent the wheel" about it. Big occupational health providers will already have their own robust and well-tested clinical governance and performance indicators in place, why would they need to bolt on additional complexity?
Dr Steve Iley, head of medical services at AXA ICAS, says: "The interaction we have with the NHS is not a lot, to be honest, and this has not come on to our radar.
"I think it will take a lot of convincing, not least because the amount of work that would have to be done just on our internal systems to make it work with clients would make it very difficult."
Proving its worth
Dr Mike O'Donnell, chief medical officer at Atos, agrees that, as yet, there is little for providers outside the NHS to grab on to, and little incentive to do so.
"At the moment it all seems rather vague, but then anything that helps employers understand how to use occupational health better is going to be a good thing," he contends.
A system such as MOHAWK could have the potential to help employers better manage health without over-medicalising things, as well as to understand what OH can bring to the table when it is called in, he argues. Moreover, if it helped over time to provide standards for specific medical conditions such as musculoskeletal disorders or depression, then that would inevitably be helpful.
"Large providers such as ourselves will do this, or something similar, already. Moreover, one of the dangers is that something like this can lead to a dumbing down as people already doing well may think all they now need to do is do well enough," says O'Donnell.
"But within OH generally, there has been an issue around a failure to understand what is expected of it. So if this can help with demystifying occupational health, then that will be useful," he adds.
"We have our own clinical governance systems, but at the same time I do think this is a very welcome development for occupational health," agrees Graham Johnson, clinical lead, nursing, at Bupa Health and Wellbeing.
"The key benefit, I think, is that people will be better able to measure outcomes, which is important of course for both practitioners and customers," he adds.
One of the benefits could be the way a system such as this helps practitioners to demonstrate how patients have responded, how they have met requirements within a given timescale and how they have demonstrated consistency, Johnson contends. To that end, it is a valuable addition to the profession, and may become increasingly so over time.
He adds: "Whether an organisation such as ours would be interested in using it is another matter because we already have, and are required to have, a clinical governance structure in place.
"Having said that, it could well be something beneficial to smaller providers and independent practitioners, especially if it is something that could be adapted."
MOHAWK at a glance
MOHAWK will involve occupational health teams measuring and inputting data once every six months, normally in March and September. Teams will need to gather some data but most of it should be readily available from their OH data systems.
Before launch, an extensive literature review was carried out, from which five evidence-based clinical outcome indicators were created:
- Indicator one - adjustments: temporary or permanent modification of work arrangements should be considered for employees who have been absent from work due to sickness for four weeks or more.
- Indicator two - timely advice: after referral of an individual to occupational health, the individual should be seen promptly and the manager should receive timely written advice from the occupational health department.
- Indicator three - patient satisfaction: all patients that are seen by occupational health departments should be afforded a high quality of care in accordance with outpatients in other medical specialties.
- Indicator four - manager satisfaction: written reports from occupational health departments to managers should be of sufficient quality to assist with the occupational management of the employee.
- Indicator five - record keeping: a further series of six core service indicators are being developed with the intention for them eventually to feed into the system.
These indicators, it is expected, will be based upon: prevention, timely intervention, rehabilitation, health assessments for work, promotion of health and wellbeing at work, and teaching and training.
Once data has been entered, each occupational health provider can see how its own performance compares with anonymised collated information from all the other units. The intention from this is to allow OH providers to begin to get a better picture of occupational health support nationally and where they are in terms of performance and effectiveness.
The intention is that further additional indicators will be added over time to provide an even richer picture of OH performance.