Those of us working in the field of OH are often accused by our NHS colleagues of working in isolation, because in the past we have set ourselves apart from mainstream healthcare provision due to the diverse nature of our workplaces.
However, in the past five years or so, there has been a distinct move by OH to align itself with counterparts in other specialities. But, just how far have we managed to re-integrate ourselves back into our healthcare roots?
I recently attended the NICE Conference in Birmingham. Those of you practising OH in an NHS environment will be very familiar with the work of NICE, but what about the rest of us?
NICE (National Institute for Clinical Excellence) was established in 1999 by the government as part of its overall agenda for improving the quality of healthcare in the NHS in England and Wales via two White Papers: ‘The New NHS – Modern & Dependable’ and NHS Wales – Putting Patients first’.1,2
More details of these planned improvements emerged with the Department of Health document A First Class Service; Quality in the New NHS’.3 The objective was clear: to ensure fair access to effective, prompt high-quality care wherever a patient was treated in the NHS. A new model was proposed, to marry clinical judgement with clear national standards, and the vehicle for this model was NICE.
The NICE organisation produces three types of guidance:
Technology appraisals: guidance on the use of new and existing medicines and treatments within the NHS in England and Wales
Clinical guidelines: guidance on appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales
International procedures: guidance on whether international procedures used for diagnosis or treatment are safe and effective enough for routine use in England, Wales and Scotland.
NICE guidance is produced to improve the quality of care provided to patients. Its mantra is: ‘Involving patients, carers and the public in development of guidance’.
Much was made of this at the recent Birmingham conference. Although NICE decisions are based on evidence provided by clinicians, researchers and patient experts, they are set against a background of social values and judgements.
To ensure public involvement, a citizen council of 30 members drawn from all sections of the population was created to debate the wider issues of national healthcare delivery. Council members reflect a cross-section of age, social circumstances, ethnicity, demography and ability. This council provides the ‘user’ side of the equation, and works alongside NICE, and the independent committees that advise it, to develop recommendations.
Most of the papers presented at the conference promoted patient and public involvement in research and initiatives, but at times it seemed that this ‘inclusiveness’ was a totally new concept to the presenters.
For a considerable time, OH nurses have been aware of the benefit of ‘user buy-in’. This has been crucial for our working populations to take ownership of issues and to realise the added value that interventions can and do bring. This is so fundamental to our practice that it has ensured the survival of OH even during economic downturns.
Health surveillance work, a huge part of OH practice, provides the very opportunities talked about in Birmingham – and involves the public in ongoing research. The extensive work conducted by the utilities sector on hand-arm vibration syndrome (HAVS) is an excellent example of this, and the Health & Safety Executive continues to monitor, support and encourage this work. Surveillance, research and education are finally beginning to slow the meteoric rise in figures of workers suffering from this condition.
Apart from public involvement in research, the work of charities was also promoted at the conference, and OHNs have been involved with this work for years. We have forged strong links with organisations such as Mencap, The Back Pain Association, AbilityNet and the Heart Foundation.
The subject of health promotion is an integral part of OH service delivery, and I believe we are finally moving away from the ‘health fair’ concept so highly-valued by misguided HR managers who believe that this is what OH is all about.
Health promotion advice and behavioural change runs through every aspect of OH, so it’s important to be fully briefed on yet another change to the government’s vehicle for its delivery.
From 1 April, the Health Development Agency (HDA)4 will be integrated into the NICE framework. The National Institute for Clinical Excellence will become The National Institute for Health and Clinical Excellence – a subtle change, although the acronym will remain the same. The HDA believes this change will not affect its practice or the consumer’s experience.
NICE clearly has big public health plans, but no means of delivering them. The regional capacity of the HDA provides an obvious solution, but what about the resources? Both NICE and the HDA are focused on the reduction of health inequalities and work with a broad social determinants model, but accessing the HDA website with an OH-related query is likely to be a frustrating exercise. After the ‘lead’ to information on healthy workplaces, you are directed to NHS Plus, and its here that health inequalities in OH truly exist.
The concept of NHS Plus, launched in 2001 to help tackle a shortage of OH provision among small and medium-sized businesses, was a truly visionary one. However, for many small businesses, trying to get advice or an OH assessment/surveillance carried out via this route can often be described as a ‘wild goose chase’. The resources are simply not there.
There was much talk at the conference of ‘tailored and targeted research, self-efficacy and integrated services’, but evidence about what actually works and what will reduce inequalities is very limited. There is a lack of data on cost-effectiveness interventions, and at one point during the conference, public health was described as a ‘health economics free zone!’
Many times during the conference, I heard the question ‘what stops interventions working?’ It seemed so obvious – lack of resources.
The need to capture evidence from practice and translate it into policy is nothing new in the world of OH. Why then, despite being key public health protagonists, was there no mention of the contribution and value of OH throughout the conference? The main programme and the parallel sessions I attended totally ignored the exciting breakthrough for public health that our inclusion in the third part of the Nursing and Midwifery Council register will bring.
Andrew Dillon, chief executive of NICE, talked of the challenges regarding the implementation of national standards, and it’s important here to mention a very relevant one for OH – guidelines to improve the treatment and care of people with depression and anxiety, which were issued in December 2004. The huge surge in psychological ill health at work is well documented, and this guidance, coupled with the HSE Management Standards, should go some way to bringing about a change in these rising figures.
Dillon talked of ‘topic champions’ – a concept with great OH potential – and the NICE organisation is actively encouraging the submission of topics to be developed into national standards. Suggestions from professional colleagues produced a couple of much-needed areas for standardisation: the access and availability for free hepatitis B immunisation for student nurses, and sickness absence management.
In fairness, both SOHN and the OH Managers Forum are consulted on the development of relevant standards, but we clearly need to invest more time and energy in working with NICE.
As a specialist group, we in OH should be proud of the headway we have made within the public health arena, but there is no beginning or end to progress. New challenges will continually present themselves in this ongoing work. In NICE, I see huge opportunities for us in this exciting new era, but there is no right or wrong way of doing things, just different choices and options. If we don’t do it, someone else will.