The government’s consultation on occupational health was very clear that the fact OH is and has always been a small specialty could hamper its ambitions to extend access to workplace health support. Occupational Health & Wellbeing and SOM brought together a high-level panel of experts to try to hammer out some answers. Nic Paton reports.
Whatever way you cut it, whether you’re talking nurses, physicians, advisers or technicians, occupational health is and has always been a small specialty.
For a government with ambitions to extend the reach of, and access to, occupational and workplace health advice and support that’s a problem. Indeed, occupational health’s capacity constraints ran through this summer’s Health is everyone’s business: proposals to reduce ill health-related job loss consultation that closed for responses last month (October).
As we reported at the time, the document highlighted the government’s concerns that the commercial OH market may not have the resources or capacity to meet future workforce health and wellbeing demand. The consultation suggested work needed to be done to “scope, deliver, manage and promote an OH workforce model and training and development approaches”.
As part of this evidence-gathering process, and to feed into the consultation, SOM and Occupational Health & Wellbeing gathered together a high-level panel in September at Health Education England to hold a roundtable discussion focused specifically on ‘the OH workforce crisis’.
The 13-strong panel included representatives from across the profession and included James Hudson, a representative from the government’s Work and Health Unit, although he was there in an observer capacity rather than as a participant.
Chaired by SOM chief executive Nick Pahl, the discussion began by considering a review of some of the workforce issues facing the profession written by GP and SOM policy intern Dr Nupur Yogarajah specifically to feed into the event. This had reached six broad conclusions, that there needed to be:
- An overarching strategy is needed to sustain and develop the OH workforce
- Better incorporation of OH into undergraduate course curriculums and extra funding to expand and front-load training
- More formalising of pathways and accreditation in postgraduate courses
- Clarity regarding which professions OH actually encompasses
- Strengthening of the NHS’ commitment to OH
- Better collection of OH workforce data
As Dr Yogarajah explained: “One of the things that pretty much everybody I spoke to highlighted was the lack of funding and resources. Everybody picked up on the fact that at undergraduate level there seems to be less exposure to occupational health; we have got fewer people coming through at that stage. From the postgraduate side, a lot of people mentioned there is often a lack of higher education institutions where people can go off and do further training in whatever branch of OH it may be.”
The role, or commitment, of the NHS to delivering occupational health was a further critical element in this complex mix. “It is really about getting a firm commitment about where the NHS will stand. And also its own in-house commitment. There doesn’t seem to be that much investment even for NHS staff, and OH is certainly very absent in primary care,” Dr Yogarajah said.
Lack of a clear picture
SOM president Dr Will Ponsonby highlighted that, whether or not you call it a ‘crisis’, the workforce challenges facing the profession are not new. “Ever since I entered occupational medicine, we’ve known the numbers have been falling and we have talked about it but we haven’t taken any action,” he said.
Dr Ali Hashtroudi, head of the National School of Occupational Health, argued that one of the challenges the profession faced in terms of funding extra training posts was the lack of data or evidence about both the situation on the ground currently and what needs to change to meet demand in the future.
“The first thing is to establish the status quo – at the moment we simply don’t know how many people actually do occupational health, in the broadest terms. I can tell you how many specialist occupational physicians there are based on the GMC’s figures. But that is where the buck stops. No one else has any idea about the rest of the plethora.
“If this consultation goes towards opening occupational health more widely to members of the public, that means the current status quo will not be enough to cater for it, so we would have to increase. But if it means we continue with employers purchasing it, it might be actually that the status quo is adequate,” he said.
“I agree there is a data issue,” said Nick Pahl. “Depending on what you see as the definition of occupational health, an average of about half the UK workforce currently has access to occupational health. If the government’s objective is that wants this to increase, even if you are going from 50% to 60% or 70% I can’t see a rejigging of the existing OH workforce is really going to allow that expansion.”
This question of definition was important, emphasised Deborah Edwards, chair of the Vocational Rehabilitation Association. “I think we need new language, I think we need new terminology and a wider scope of definition of what ‘occupational health’ is and, in particular, one for people who aren’t working and don’t have any support to get back to work if they don’t have a job or are on zero-hours contracts.”
OH for all, not just those in work?
“I agree with that. Let’s support that idea of provision for employed and unemployed,” said Leicester GP Dr Rob Hampton, representing the Royal College of General Practitioners. “In our practice we see the difference around dealing with people in employment and out of employment. It is almost discriminatory that people who are out of work, and with most need, do not have access to OH and OT.
“The other area is people in the gig economy, the self-employed, those working with agencies who I still feel won’t be covered by a lot of the SSP [statutory sick pay] improvements in this paper. In my own particular practice we have an awful lot of people who weren’t born in the UK and they tend to work in gig or agency work, and there is exploitation,” he said.
“Is it worth looking at other areas of practice that are also facing workforce challenges and see what their solutions are? And then we may be able to import those into occupational health,” suggested Genevieve Smyth, professional adviser at the Royal College of Occupational Therapists.
Emphasising the feasibility of using OH and occupational medicine as a springboard to a more flexible ‘portfolio’ career could be one way of making the profession more attractive to trainee doctors, especially those wishing to work more flexibly, suggested Dr Yogarajah. “I think that is filtering through, these options of working more flexibly and incorporating other things in rather than just having one focused speciality,” she said.
One barrier for nurses looking to make the transition into OH was often the fact they had to take a pay cut to do so, highlighted Christina Butterworth, then chief operating officer (now retired) at the Faculty of Occupational Health Nursing. “Nurses will train in the NHS, get up to band six, seven or eight but then to go into occupational health they have to go back down to band five.
“The other part is about upskilling; I think it is really important. We have got a great lot of people, a lot of experienced people, but they are still doing basic jobs. And we need to upskill the workforce that is presently there to take on more of a leadership role. One of the vital roles we have is to advise employers what good occupational health is and how they can work in partnership to improve the overall health and wellbeing of the organisation,” she said.
Within occupational psychology it is essential to focus at the organisational level at the onset to address business and organisational issues, rather than to start at the individual level to address occupational health and wellbeing, which may be adversely affected by said organisational issues, said Dr Roxane Gervais, member of the British Psychological Society. “I think it is just understanding how we can contribute; how we can make organisations more productive.”
Dr Hampton highlighted using the pyramid model (something already on the radar of Health Education England) as a way for different arms of the profession to learn from each other but also more widely. For example, he outlined how drug and alcohol services tend to use a multidisciplinary case management and referral model.
“If there was a ‘we are going to design a national OH service’ and maybe restrict that to SMEs, then the model of what goes on in drug and alcohol services could be one to look at. Because most of the work there is with non-clinical case workers and then there is an upscaling and downscaling of need, depending on where the person is with their ‘journey’. When there is a medical problem it goes up and down that hierarchy and it works really, really well,” he said.
Sharing of workforce data
At this point the discussion moved on to consider a number of specific questions raised in the consultation. First was the likely willingness of providers to submit information on the make-up of their workforce to any new co-ordinating body. This led to fierce debate around the definition of the term ‘provider’ and how even you should define ‘your workforce’ in the context of occupational health provision.
As Miles Atkinson, chartered physiotherapist and chair of the Association of Charted Physiotherapists in Occupational Health and Ergonomics (ACPOHE), put it: “There are only 350 ACPOHE members (Physiotherapists with specialist training in Occupational Health) who may handle the OH elements of the patients care, but often treatment is undertaken by thousands of physiotherapists with no specific training in Occupational health, so it is unclear how we would classify these clinicians?”
Similarly, Kelvin Williams, president elect of the British Occupational Hygiene Society, said: “It comes back to that point of how do you define occupational health delivery? For example, even just within occupational hygiene you have different disciplines. You can have, say, a noise specialist or a ventilation specialist. That skill – occupational hygiene – goes across seven disciplines.”
“If you bring in someone who has been injured at work, you may have eight case managers working with him who don’t work for the employer at all,” added Deborah Edwards.
“If you have someone [doing occupational health] in-house, they can tell you about that database,” said Christina Butterworth. “But if it’s HR that is running your occupational health, do they understand that somebody else has been called in to help? Who has commissioned that piece of work? It could just be a line manager who did it.”
Then there could be unforeseen consequences, warned Genevieve Smyth. “I have seen a problem that has happened in the past where organisations have disclosed their workforce data and another provider has got hold of that information and has said ‘well I see you are operating your service with only one occupational therapist, I’ve been employing three OTs, maybe I don’t need three?’. And that would have the unintended consequence of not increasing but decreasing your workforce because it gets driven down to the lowest common denominator. That is a potential risk.”
“This is almost an impossible task. If you ask the big providers you still don’t get a picture of the workforce. Urging providers to give you that data won’t give you an idea of the workforce because the workforce is disparate,” highlighted Dr Hampton.
Private OH training?
The next question the panel were asked to consider was whether private OH providers should be involved in the training of the clinical workforce.
“What we need to do is to make sure the training that goes on in the private sector is at least the equivalent of what goes on in the NHS in terms of quality, and that people get proper training and proper time off for study leave and so on,” said Dr Ponsonby.
Christina Butterworth also highlighted the importance of having a credible end-point assessment. “It is who is assessing those people competently at the end of their training; that is so important. How will they know what ‘good’ looks like if they’re not actually specialists themselves?” Alongside this there needed to be focus on access to high-quality continuing professional development, she added.
The final consultation question was ‘should there be a single body to co-ordinate the development of the OH workforce in the commercial market?’.
Dr Hashtroudi was adamant there already was one body that could help with training side of developing people: the National School of Occupational Health. “But it has to be resourced to look after everybody, not just the medical workforce. You do not need to have a different organisation, with different governance, for the commercial side. There does not need to be a different body, you just need to resource the body that exists already,” he said.
As the discussion drew to a conclusion, Nick Pahl asked participants for their closing reflections.
“I think it is the definition of who is included within it [occupational health], because that seems to hinder on so many things, for example how the workforce models will be created,” said Dr Yogarajah. “And I think the issue of postgraduate education is important; how we are going to integrate and standardise things.”
“I’d like to see better use of our GPs who have a diploma with an interest role from faculty and the National School of Occupational Health and the college as well,” said Dr Hampton. “But I think there is a wider point, too. There is such heterogenicity of professions here, and it is like no other area I have come across. It’s going to be very difficult to have an umbrella solution on workforce that fits everything. So the question is what can we achieve? And I’m afraid I don’t have the answer to that. But this discussion has made me realise how difficult it is.”
Genevieve Smyth said that, for her, encouraging greater use of the pyramid model would be valuable. “I think there is great mileage in the pyramid model, using that as the way to frame how we’re going to expand the workforce at all of those levels: universal, targeted and specialist. I do also think we need to think more about how can we skill up the universal part of the workforce.”
Dr Hashtroudi echoed this. “I am encouraged by the interest in the pyramid model. What I want to do when we go away from there is have better communication with all of you round this table; to learn from each other and actually get actions from that. There are things we can learn and actually use. For me, it is all about enhancing our collaboration and getting everybody around the table to actually help us to build that pyramid.”
Deborah Edwards agreed the way everyone had come together around the table was in itself positive. Within this there was a need to “identify all of these different areas that do contribute to the whole spectrum of getting people back to work and keeping them in work”, she said. “Doing that work, identifying who they are and what groups they are in. And then you can start looking at how you bring them together at that point of time.”
Dr Ponsonby highlighted the need to promote the attractiveness of OH as a flexible, portfolio career. “We have people wanting very different lifestyles now, including doctors and nurses in terms of the way they work and train and so on. I think the pyramid model fits with that in that they can choose where they fit within the pyramid. I think occupational health potentially also fits with that because it gives freedom in terms of lifestyle and things which some of the other specialties don’t have.
“The other thing is we should think about technical solutions. So the use of apps, communication tool, all of these things. And then the last part is we should be thinking about training the non-medical/HR/line managers to be more effective in managing these things,” he added.
As this point Noorzaman Rashid, chief executive of the Chartered Institute of Ergonomics and Human Factors made his first contribution, having held back because of only having been appointed to the post the week before and, therefore, much of the discussion had simply been about learning and observing.
He argued that, if the profession wanted the government to listen, it needed to frame its ‘wish list’ around the economic arguments and benefits. “Rather than us telling the government how much better we can practice, how much better we can learn and train each other, it needs to be the economic argument in terms of the actual problem we are trying to solve for the country. We have to provide data on the economic arguments. One of the starting points is a huge piece of work on workforce analysis and the skills profile in each of the spheres of influence. That’s my take.”
Dr Gervais highlighted the need to emphasise to organisations that they have a legal responsibility to keep people healthy and safe within the working environment. “It is about prevention – and occupational psychologists can add value by going into organisations and looking at the structure, looking at the focus, and then showing how they can actually not make people ill and fall out of the workplace. Treatment is fine but we need to start with fewer people actually leaving the workplace because of ill health, bullying or harassment or whatever, which can cause depression.”
“I would echo that,” said Kelvin Williams, “the need to focus on prevention, for example through occupational hygiene courses. I would like to see more emphasis on that.”
“For me it is very much about looking at what leadership is,” said Christina Butterworth. “It is really going back to first principles. We need to think more about how we care for people. Everything focuses on the 5% of people who are sick, and we don’t learn the lessons from them 95% who are well and working effectively.”
“For me it is about structure,” added Miles Atkinson. “It would be good to get some movement on structure. It could be the pyramid model piece, and the right people at the right time. And then also it is about training I think; that is one of the needs that we need to keep working on.”
Nick Pahl then brought the discussion to a close with some final thoughts. “I agree we need to look at what other sectors have done in response to occupational crisis; I think it would be useful to scope that out.
“I also think we need to think more about the data and how we collect data and what would that look like? And thinking about leadership, we need to get the bases right and the training pathways and the CPD. We need the next generation of leaders who can help us get through. For example, I would love to see a master’s in occupational health leadership where people from different professional groups come together. We do need that change to happen.”
- Dr Nupur Yogarajah, GP extensivist, Croydon Hospital, clinical project lead, Medicines Management, Greenwich CCG, policy intern, Society of Occupational Medicine
- Miles Atkinson, MSK corporate service lead for Vita Health Group and chair of the Association of Charted Physiotherapists in Occupational Health and Ergonomics (ACPOHE)
- Christina Butterworth, chief operating officer (now retired), Faculty of Occupational Health Nursing
- Deborah Edwards, director, consultant and case manager, RTW Plus, chair, Vocational Rehabilitation Association
- Dr Roxane Gervais, chartered psychologist and HCPC-registered occupational psychologist, member of the British Psychological Society
- Dr Rob Hampton, Leicester GP and representing the Royal College of General Practitioners
- Dr Ali Hashtroudi, clinical director, Guy’s and St Thomas’ NHS Foundation Trust, director of occupational health services and head of the National School of Occupational Health
- James Hudson, lead of the analytical team focusing on occupational health at the Work and Health Unit, Department for Work and Pensions and Department of Health and Social Care
- Nick Pahl, chief executive, Society of Occupational Medicine (chair)
- Dr Will Ponsonby, president, Society of Occupational Medicine
- Noorzaman Rashid, chief executive, Chartered Institute of Ergonomics and Human Factors
- Genevieve Smyth, professional adviser, Royal College of Occupational Therapists
- Kelvin Williams, president elect, British Occupational Hygiene Society
Health is everyone’s business: proposals to reduce ill health-related job loss, July 2019, Department for Work and Pensions and Department of Health and Social Care, https://www.gov.uk/government/consultations/health-is-everyones-business-proposals-to-reduce-ill-health-related-job-loss
What government’s workplace health consultation means for OH, September 2019, Occupational Health & Wellbeing, https://www.personneltoday.com/hr/what-governments-workplace-health-consultation-means-for-oh/
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