Pippa Crouch explores the origins of the occupational health technician, how their role has evolved, and what their responsibilities are.
Historically occupational health (OH) has sat quietly in the background of medical practice, an unassuming branch of medicine which remains under-utilised by organisations. This is well-recognised by the Society of Occupational Medicine (SOM) which has launched its Universal Access to Occupational Health Campaign, which aims to increase access to occupational health services nationwide.
It is frequently stated that only 50% of employees have access to OH, but this appears to be overinflated. It could be as low as 14% (Nicholson 2021).
Whilst the pandemic has resulted in health becoming firmly ensconced in people’s minds, OH has gained recognition since Dame Carol Black’s review of the health of the working population (Black 2008). Yet, a more pressing question remains largely unaddressed: are we as a specialty fully equipped and ready to respond to a potentially significant increase in demand?
This question becomes especially important when considered in the context of rapidly declining numbers of OH physicians and nurses. There has been a 21% reduction on part 3 of the specialist community public health nursing (SCPHN) register over the last six years (NMC, FOI request). This begs the question: are our current service delivery models fit for purpose, or do we need to rethink how we can deliver best support to the working population? Could the development of the OH technician’s role be the answer?
This article, the first in a series of two, will consider the role of the occupational health technician (OHT) specifically to addressing these concerns. This first part considers the origins of the role, because without understanding where or how it evolved within the wider context of health, it is impossible to plan for the future.
The occupational health profession
Origin of the OHT
As with any good story it is always best to start at the beginning, yet this is where we encounter the main stumbling block. Both the OH physician and nurse have clearly defined origins; the Swiss Physician Paracelsus who in the 15th Century recognised the link between ill health in mining (Grandjean, 2016), and Phillipa Flowerday, Coleman’s Mustard Factory’s first industry nurse (Thornbory and Everton, 2018). However, the role, function and history of the OHT has not been clearly referenced or documented; it simply seems to have appeared in the 1990s.
One school of thought is that the role developed from that of undertaking audiometry and spirometry in response to increasing demand for health surveillance following statutory guidance. It is noteworthy that a similar role existed in military settings and in coal mines. In some settings it may have developed as an extension of the role of the health and safety adviser (again undertaking health surveillance as the competent person).
Regardless of how the role emerged, it appears to have coincided with a period of notable change within the NHS; especially within the field of nursing and the implementation of Project 2000 (UKCC, 1986) and the subsequent creation of the healthcare assistant (HCA). It appears that the role of the OHT has developed organically, mirroring that of the HCA.
The healthcare assistant role
To explore this further, an understanding of the evolution of the HCA role is helpful. Throughout history the role of the nurse is well documented and the origins of nurse’s aide can be traced back to the Crimean war, (Goodrick and Reay, 2020) but the HCA role itself remained nebulous and poorly defined (Kershaw, 1989). Whilst the Health Care Act of 1919 tried to address this, it took until 1955 where the term ‘nursing auxiliary’ became recognised. In 1984 The United Kingdom Central Council undertook a review (UKCC 1986) which resulted in the implementation of Project 2000, however it was only in 1999, when the Department of Health and Social Care published its document ‘Making a Difference,’ that it became apparent that the HCA sat within the framework of nursing, and that HCAs needed to be educated and trained to NVQ levels (Department of Health and Social Care, 1999).
HCAs have a duty of care and legal responsibility to the patients they assess, but not being registered with a professional body such as the Health Care Professionals Council (HPCP) limits their role. Employers have a responsibility to train, supervise and have oversight of their HCAs and assure their competence. They are also liable for their employees, and are accountable for the acts and omissions as outlined within their contract of employment.
At present, there are no specific entry requirements to become an HCA, other than good English and maths skills (NHS Careers, 2021). Within the NHS they would commence on a band 2 role (salary of £18-19K). Once engaged, the HCA will be expected to undertake the Care Certificate produced by Skills for Care, which incorporates a set of standards collectively developed by Health Education England, Skills for Care and Skills for Health and designed to meet the requirements set out in the Cavendish (2013) and Francis (2013) reviews that aimed to address inadequacies in the education of health care practitioners.
This standalone certificate (and now an accelerated course) can be undertaken by anyone new to working in the care sector. The standards are:
- Understand your role
- Your personal development
- Duty of care
- Equality and diversity
- Work in a person-centred way
- Privacy and dignity
- Fluids and nutrition
- Awareness of mental health, dementia and learning disability
- Safeguarding adults
- Safeguarding children
- Basic life support
- Health and safety
- Handling information
- Infection prevention and control.
From here, HCA’s can progress up the NHS banding to band 3 (salary of £20-£22K) available to HCA and those undertaking a therapy role. Further qualifications can be attained, such as the level 2 and 3 diploma in care or qualifications through an apprenticeship (NCFA CACHE level 2 or level 3 diploma) such as a nursing associates (band 4 – around £22.5-£25k) or progression to the nursing degree at band 5 (once qualified – between £22.5-£31k). Additionally, career pathways such as midwifery, occupational therapy, speech and language can be considered.
More CPD resources
Within the NHS the evolution of the HCA is clear, and roles and responsibilities are commensurate with their banding and associated pay scales. Looking across the healthcare sector, a similar role has developed within general practice (also independent of the NHS), which again appears to have emerged in response to demands and staffing shortages (Working in Partnership Programme, 2007). The role of the non-registered healthcare professional has evolved in recent years, its trajectory mirroring that of the development of the physician’s aide in Europe (Stewart & Catanzaro, 2005).
The role of support workers in healthcare appears to have gained greater recognition over the last decade. Within the NHS it is now underpinned by a set of recognised standards, unlike within OH. Previously, their role appears to have largely been determined by the needs of practice and the extent to which delegated practice occurs (Bates, 2004).
Healthcare support worker role
Within primary care it took until 2017 when Health Education England set out a framework via the healthcare support worker (HCSW) training which marries the correct roles to responsibilities, skills and competencies underpinned by an educational pathway with general practice. Again, the core requirement here is for the Care Certificate to be completed.
Their roles and responsibilities (Petrova, Vail, Bosley and Dale, 2010) are:
- Blood pressure checks
- New patient health assessments
- Height and weight measurements and BMI calculations
- ECG reading
- Peak flow measurements
- Flu vaccinations
- Applying simple dressing
- Coronary heart disease checks
- Removal of sutures
- Diabetic checks
- Health promotion: distributing lifestyle literature – undertaking smoking cessation and obesity clinics
- Cleaning and sterilising equipment
- Monitoring vaccine storage and ordering vaccines / restocking.
The HCSW role is defined by the Nursing and Midwifery Council as: “Those who provide a direct service – that is they have a direct influence/effect on care and treatment to patients and members of the public and are supervised by and/or undertake health care duties delegated to them by NMC registrants” (NMC 2006). They should work at all times within the boundaries of delegated authority and personal level of competence and training.
Within the NHS and general practice, the boundaries of the role of support workers are clear and responsibility to work under delegated practice is also made apparent. There are established entry routes and career progression available with pay scales commensurate with skill level, all of which is underpinned by a clear clinical governance frameworks and educational pathways.
Career structure of the OH technician
Bosley and Dale (2008) compare the role and career structure of the OHT to that of an HSCW, which recognised the dangers of transferring hospital-based evidence practice to the general practice. Furthermore, within OH there is a greater potential for isolation within practice than for HCAs employed within primary or secondary care. Many OHTs undertake health surveillance at client sites but are not accompanied by a registered healthcare professional. At present there are very few minimum standards or entry requirements for an OHT as with that of the HCA. However, this is really where the similarities end; there are no expectations with regards to skills or competencies and this appears to be largely dependent on the employing or commissions service provider.
Inside the NHS, the role of the OHT has only recently been recognised; there is no record of it within the Agenda for Change, only that of a HCSW or occupational therapy technician. It is possible that the OHT was initially considered within the remit of the HCSW and is only just gaining recognition. A quick search shows that within the NHS OH technician roles are now being advertised, with most roles being advertised at band 3.
Has OH missed an opportunity and if so, how, and why has this happened?
Dame Carol Black’s 2008 review set the stage for the growth of occupational health. Johnson (2010) states that the RCN’s Public Health Forum then sponsored a workshop, encompassing representation from across the sector developing the ‘Standards and Competencies for OH Technicians’. These standards, published in 2011, (RCN 2010) were created around the same time as the appetite for regulation of HCSW increased with calls for greater regulation within the profession, with a report being commissioned by the Nursing Midwifery Council (King’s College 2010). As such the introduction of these standards was timely as they mirrored the HCA pathway within the NHS.
Their objectives were to:
- consider the need to develop national standards of competences for occupational health support workers (OHSWs), which is another name for OH technicians
- identify the main areas of practice and how these links with the role of NHS HCSWs
- consider whether existing HCSW educational material could be used to form the base for OHSW training
- agree the specific domains under which standards would be developed
- explore the specific additional skills which should be acquired by the OHSW working in an occupational health setting (RCN 2010).
The RCN defined a technician as: “An occupational health support worker (OHSW) is an individual who delivers occupational health services to and for individuals and groups. OHSWs will have a required level of knowledge and skills in the recognition of the influence of their work on health and will work under professional supervision within the guidance of established protocols and procedures.” (RCN 2010)
Their role and scope of practice at level 1 were clearly defined by the RCN:
- basic knowledge of anatomy and physiology
- basic life support
- principles of infection control
- confidentiality, accountability, and data protection.
In accordance with relevant occupational and industry standards and protocols, OHSWs should be trained, using National Occupational Standards (2011) where applicable, and assessed as competent to:
- measure blood pressure, pulse, height, and weight including BMI
- undertake urinalysis
- contribute to the assessment of new starter questionnaires
- undertake audiometry
- measure visual acuity to occupational standard
- measure colour vision to occupational standard
- do lung function testing to include peak flow and spirometry
- assess mobility
- undertake drug and alcohol testing
- keep records
- use communication skills
- use IT skills
- use health and safety legislation (for example: Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations, Control of Substances Hazardous to Health Regulations, Display Screen Equipment Regulations)
- include concepts of health promotion and prevention of ill health
- order stock.
At level 2, the roles and responsibilies are the same as level 1, plus:
- undertake ECG recordings
- interpret food handler questionnaires
- administer the Chester step test
- skin assessment
- hand arm vibration syndrome (HAVS) assessment to level 1 and 2
- occupational health hazards and risk management.
Some 12 years later, there has seemingly been no further action from the RCN group and the working party was disbanded. On contacting the RCN it became apparent that they no longer hold records of the consultations. It appears that their records are untraceable and locating the above standards has proven to be difficult.
This article has reviewed the evolution of the role of the OHT and lays the foundations for the second article in this series, which will explore the barriers to education and general challenges facing OHTs.
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