Independent occupational health practitioners are at risk of being squeezed out of the market by larger providers. But SEQOHS and technology could be the key to making smaller providers competitive, argues OH single-hander Nic Lee.
Many small and medium-sized enterprises (SMEs) avoid paying for OH, and larger OH providers are reluctant to meet the need for an affordable and easy-to-use service that is available on an ad hoc basis (Faculty of Occupational Medicine (FOM), 2006). This suggests that a gap in the market exists for single-handed providers to step in and provide one.
The gatekeepers to this market are the HR managers who increasingly represent the interests of SMEs, and it is they who must be convinced that cancelling or curtailing OH provision will not improve their clients’ bottom line, regardless of the economic outlook (Ballard, 2014).
By commissioning an OH service, SMEs can protect themselves against litigation by not compromising the legal rights of their workforce. The most cost-effective way to achieve this is through pre-placement health screening, which should constitute the cornerstone of SME health and wellbeing (Ballard, 2013).
The Government’s Fit for Work service, currently being launched in phases throughout the UK, seems unlikely to meet the demand for more responsive OH provision (Black, 2008; Waddel and Burton, 2006).
Under Fit for Work, employers are generally dependent on employees requesting a GP referral into the service and, until SMEs can make direct referrals to the scheme, its coverage will be limited. The British Medical Association (2014) has expressed reservations about the service, arguing that: Fit for Work’s limited remit (remotely managing employees absent for four or more weeks) makes it a reactive rather than a proactive service; it has limited capacity (the provider of this service within England and Wales has recruited less than 20% of the required workforce and recently targeted general nurses and allied health professionals to meet its quota); and there is a risk that return-to-work plans fail to inform SMEs how they should determine what reasonable adjustments are required to help employees return to work.
Essentially, the Fit for Work service will complement, rather than replace, existing OH provision. Nevala et al (2015) support the need for a more specialist opinion than the Government or HR can currently provide on workplace adjustments. Another limitation is that the Fit for Work service is unable to promote workplace health before a job candidate starts their job.
The NHS Health at Work network is another OH service provided in the public sector. It has struggled to make a profit from delivering an affordable service to SMEs, because NHS Plus managers are being refused the funding to recruit and train the additional staff required to do so.
Single-handed OH providers could gain from this, particularly if they obtain a Safe Effective Quality Occupational Health Service (SEQOHS) accreditation.
SEQOHS standards changed to support single-handers
In December 2010, the FOM established standards for accreditation under SEQOHS. The original aim of these was to enable NHS organisations to offer outstanding OH provision and to ensure that their employees’ health and wellbeing was in line with the Government’s Public Health Responsibility Deal (Department of Health, 2011).
Five years on, the SEQOHS quality assurance mark now enables 163 accredited members to differentiate themselves from the competition when bidding for business (FOM, 2015). However, single-handed practitioners have had limited opportunities to see the benefit of accreditation, due to the time and money involved.
This situation has improved following the faculty’s announcement of a number of limited, but substantive, changes to the process. One change is the reduction of the cost for sole practitioners to register and renew their annual SEQOHS accreditation to £250 per annum, compared with up to £2,000 for larger providers. Furthermore, the evidence required to meet the standards has been more clearly laid out and aligned with the needs of single-handed providers.
The previously separate NHS-specific standards have been integrated into the six core domains (Johnston, 2015). This simplified process makes accreditation far more cost effective for independent practitioners (Cosgrove, 2011). The revised SEQOHS standards will remain in place until they are reviewed in 2020 (FOM, 2015), and the evidence required to meet these standards will be regularly updated on its website to reflect any legislative changes that could impact on OH services.
The biggest change, however, is the introduction of guidance specifically aimed at single-handed providers, and the publication of the evidence required to meet the standards, relevant to those that offer a limited remit of services. This will potentially widen access to independent practitioners
without diluting quality. Of the six core standards, the minimum requirements for meeting business probity, and the facilities and equipment standards, have been significantly reduced for the single-handed provider.
One of the unpublicised benefits of the revised SEQOHS process is that it provides registered nurses with an online portfolio and repository in which to store and download much of the evidence required for professional revalidation by the Nursing and Midwifery Council (NMC) every three years.
To meet the requirement of the SEQOHS people standard, a service provider must give proof of professional indemnity insurance, while proof of continuing professional development, such as evidence of ongoing clinical audit and peer review of clinical records, is needed to meet the requirements of the information governance standard.
The final two standards, relationships with purchasers and relationships with workers, both enable the use of practice-related feedback from clients and their job candidates to be used, either in the form of testimonials or anonymised feedback solicited via the use of online surveys.
Negative feedback is all too common in OH, where the client and employee often disagree with the clinician if a management referral does not go their way. The five pieces of feedback required by the NMC can be used alongside those required by the FOM in a positive way, and, as counter-intuitive as it may sound, soliciting negative feedback enables the provider to write a reflective account that can be used as continuous professional development. This demonstrates to the client, the NMC and the FOM, that they are using such feedback to improve their practice.
Single-handers can support SMEs
Independent OH practitioners implementing these changes are able to demonstrate to purchasers that they are accountable for their actions and should therefore be better placed to win contracts than their non-accredited peers.
OH professionals are used to being challenged by, and collaborating with, HR employees and line managers, and the key to the single-handed practitioner achieving a sustainable income is to sell their professional credentials to those HR providers that represent SMEs. This should avoid the expense of an advertising campaign and the time required to build a client base one company at a time, although many smaller clients constitute a more secure and reliable source of income over the longer term than one or two large clients do.
Single-handed providers can serve SMEs at a lower cost than larger OH services, and where practicable, enable them to meet their legal and regulatory responsibilities under the Health and Safety at Work Act 1974 and the Equality Act 2010.
HR providers can solicit pre- and post-employment risk assessments and statutory health surveillance, and also make management referrals on behalf of their clients. This will enable independent practitioners to prevent sickness absence from becoming a long-term or a recurring problem. This is especially applicable to SMEs, given that sickness absence cost the UK almost £29 billion in lost revenues in 2014 (CIPD, 2014).
SEQOHS registration could open up commercial opportunities to independent practitioners providing OH services to the NHS for a number of reasons. The Office for National Statistics (2014) identified workers in the health sector as having the highest rates of sickness absence in the UK. The NHS faces a contraction of its workforce, following tighter controls on immigration from outside of the EU, an ageing workforce and the lack of consistency in workforce planning due to the potential change of government every five years (Royal College of Nursing, 2015).
This is where SEQOHS accreditation can guide SME purchasers and their gatekeepers, as well as recruitment agencies supplying the NHS with healthcare workers. Accreditation can also reassure clients that ad hoc pre-placement health screening and management referrals are not only cost effective, but compliant with the standards set out in the existing NHS Employers framework agreement (Crown Commercial Service, 2013).
The Council for Work and Health (2011) has estimated that the number of Specialist Community Public Health Nurses registered as OH advisers with the NMC at approximately 3,300. The council’s latest report confirmed that more OH professionals are required to manage the health needs of an expanding and ageing workforce, especially those employed by SMEs (Council for Work and Health, 2014).
How can OH single handers compete with the big providers?
Single-handed practitioners are hindered in charging a premium for their specialist knowledge by the power of the larger OH providers, who are consolidating their power base and increasing their market share through merger and acquisitions. Such providers own or license the software required to supply their clients with the service that they demand and that many SMEs cannot access.
Availability of OH software solutions for sole OH providers has failed to keep pace with the revised SEQOHS standards, with systems offering fixed features, such as the ability to record hand-arm vibration syndrome and audiology assessments better suited to larger OH services. Sole providers need a system that clinicians can use intuitively, which is accessible on any device, and simple enough for clients to securely refer candidates to for pre-placement health checks, annual health surveillance and online management referrals. However, they would have to pay a premium for providing feedback to improve a product that they are already committed to using (Nielsen, 2014).
The cost to build such a system and integrate it into an existing website is prohibitively expensive for a single-handed provider to consider, unless the provider is working directly with a programmer to make it SEQOHS compliant and so can reassure clients and clinicians that it is truly fit for purpose. With the larger OH providers commissioning online platforms to replace their outdated applications, the future for single-handed providers is not likely to be secured through SEQOHS accreditation alone.
The OH profession is stratifying into those who provide their services on a single-handed basis, either as a private limited company or as a self-employed individual, and those who are employed by an in-house or external provider. Combined with SEQOHS accreditation, the entrepreneurial sole provider has the potential to create their own niche by meeting the needs of SMEs and breaking the monopolies constraining the market for health screening NHS nurses pre-placement.
The single-handed practitioner still needs the tools, however, otherwise they can face increasing reliance on larger OH providers for contract work, for example, screening new clinicians.
Larger providers often contract work to independent practitioners for certain purposes, for example to prevent the provider’s own practitioners having to assess future colleagues’ potentially sensitive medical information (NMC, 2015), and to take advantage of lone practitioners who own and calibrate their own surveillance equipment to provide peripatetic ad hoc health surveillance at a fraction of the fee that a larger provider would receive.
Until these challenges are overcome, the vast majority of single-handed providers will be unable to meet the needs of the SME market, even with SEQOHS accreditation.
Tools for the future
Independent providers need tools that can enhance their clinical judgment and ability to advise employers on how ill health impacts their employees’ capability in the workplace.
The Government has a poor track record for delivering a national programme for IT in the NHS (National Audit Office, 2013), which suggests that an independent provider is best placed to develop an online OH programme audited by SEQOHS. Such an operator could act independently without relinquishing any power to the larger providers, by forming a peer-to-peer network of single-handed practitioners using a collaborative platform to supply their SEQOHS-accredited knowledge to meet the demand for pre-placement, health surveillance and management referral work.
Such a system could ensure that service level agreements are adhered to without requiring an expensive administrative team, and enable confidential data, such as medical information and reports, to be encrypted as per SEQOHS requirements.
This system could be sold to SMEs and their outsourced HR providers to mitigate costly sickness absence and ill-health litigation, as well as to support the recruitment and retention of a healthy workforce. The demand from clients and clinicians is there, and a sole provider now needs to supply the means to deliver it.
References
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Royal College of Nursing (2015). Frontline first: the fragile frontline (accessed 4 May 2015).
Waddell G and Burton AK (2006). “Is work good for your health and well-being?” London: The Stationery Office.
