The role of occupational health looks conspicuously absent from Lord Darzi’s Next Stage review of the NHS. Nic Paton finds out how it is being interpreted.
When the final report of Lord Darzi’s Next Stage review of the NHS was published in July, it was hailed by prime minister Gordon Brown as a “once in a generation opportunity to improve the NHS”. It didn’t take long for the cynics to point out that this made it the fourth “once in a generation” report on the health service in the past decade. Nevertheless, Darzi’s report is important, not only because of the clout that he, as a working surgeon, carries in the corridors of the Department of Health but also because of the current emphasis on the need to reform workplace health if we are ever to tackle properly the wider ills and ailments of the nation.
While, as Occupational Health went to press, the profession was still awaiting the government’s response to Dame Carol Black’s Working for a Healthier Tomorrow review – with it now not expected to be published until October – the signals are relatively positive. Rumours abound, for example, that one of the pilots for Black’s Fit for Work occupational health service has already been pencilled in to be sited within one of the government’s new “polyclinics”. Whether this actually happens, of course, is still to be seen but it does seem to indicate that ministers are serious about needing to reform the delivery of and access to workplace and occupational health interventions.
Which makes it all the more surprising that occupational health is, if anything, most conspicuous by its absence from Darzi’s review. OH, it appears, may have once again lived up to its reputation as a Cinderella specialty – not invited to the Darzi ball.
As Susan Gee, OH manager at Bradford Metropolitan District Council, puts it: “That was the thing that most bothered me about it. It comes across, to me at least, as quite idealistic, although I appreciate a lot of work has gone into it.”
Caroline Whittaker, senior lecturer at the University of Glamorgan’s Faculty of Health, Sport and Science and a member of the RCN’s Society of Occupational Health Nursing, is equally cautious in her welcome of it. The report, she points out, completely ignores such important issues as the fact that most people do not work in large corporate organisations or have access to OH.
“Personally I find it very much geared towards secondary care. While recognising the importance of work, it has not been appreciated that the majority of people work in small organisations. So I see it as a missed opportunity to hammer home the fact that the public sector needs to be taking a lead on this,” she says.
The Darzi review certainly makes a lot of positive noises, with its supplementary Primary and Community Care Review (see box) in particular focusing on the need to improve access to services at a ground, local and even employer-based level. It has recommended that access to GPs be widened massively, that patients have individual health budgets, that mental health becomes much more of a priority, that there be more community-based services and that there should be more “joined up” return-to-work services, much of which echoes Black’s recommendations.
But the devil is in the detail, or lack of it, points out Gee, whose council has been piloting an initiative of proactive collaboration with local GPs, including allowing GPs (with the consent of the patient or employee) to refer directly into the OH unit.
Personal budgets, for example, are all well and good but there has been no debate about whether an element of that should be available to employers to spend on helping patients back into work, she points out.
Clearly, this would be controversial but, if the government is serious about bringing workplace health into the mainstream agenda, it is something that should at least be considered, Gee argues.
“A lot of councils have struggled with the concept of recognising that NHS services are not there on tap. Dealing with employers does not come high up on the agenda,” she says.
Given, too, that any national occupational health service, whether a Fit for Work service or some other network, simply could not be run by the NHS in isolation, employers need to be being talked to more, Gee argues.
“There need to be some incentives for employers. The problem with the report is that it is not specific enough. It needs to be saying that there should be more partnerships between employers and employees within primary care,” she adds.
“I would like to see a greater acknowledgement that the NHS cannot do this in isolation it cannot be the be-all and end-all. There has to be an acceptance that work and health is everyone’s problem. It is about employers understanding that good health is good business – it is a cliché but it is true,” she continues.
Which bring us, in turn, to the often thorny relationship between GPs and occupational health practitioners. As Bradford has found, this need not be adversarial and suspicious – in fact GPs are often only too willing to have someone they can, within appropriate limitations, pass on some element of their workload.
“We have to sell it to GPs by saying if you do not want your surgery full of people whose needs you cannot address, then you can come to people like us,” Gee explains.
“GPs sometimes do not understand the consequences of interacting with OH. I have had GPs ring me up and complain that I am trying to get a patient of theirs back to work. So I have to emphasise that I am not questioning their right to say someone cannot work.
“GPs sometimes get the wrong idea about their guardianship role. In many cases by signing them off work they may in fact be doing the patient a disservice that if they continue to sign someone off excessively the risk is that they will simply be released or be forced to take medical retirement or whatever,” she adds.
There is certainly scope for primary care and occupational health to work more closely together, agrees Dr Paul Grime, consultant in occupational medicine at the Royal Free Hospital and the chairman of the occupational health committee of the British Medical Association.
When assessing a patient, GPs (and, it has to be said, secondary care doctors and nurses too) should be considering a patient’s health in the round – including their work and the impact, whether positive or negative, of their work on their health, he stresses.
“Whenever we as OH professionals write to a manager about someone who has been referred to us we should be routinely copying in their GP,” Grime suggests, for example.
“Occasionally GPs will contact us on the basis of a report that they have been sent or they will write to us. It is starting to happen but I think there is still an awful long way to go,” he explains.
The current system of fees for writing reports can act as an obstacle to communication between GPs and employers, Grime also argues.
Currently, if an employer asks a GP to write an occupational health report, whether for pre-employment purposes or as part of some other assessment of fitness to work, it falls outside their normal NHS responsibilities and is supplied, at the GP’s discretion, on a private basis.
But, if workplace health is now to move into the mainstream health ambit, it surely makes more sense for these reports to become part of a GP’s NHS responsibilities, suggests Grime.
“The difficulty is that whenever you try to discuss fees with GPs it is quite a difficult subject to broach,” he admits.
Nevertheless, Grime did succeed in getting a motion agreed at this summer’s BMA annual conference calling for the association to review its guidance on such fees.
The motion expressed concern that “fees for communication between occupational health professionals and others can sometimes be an obstacle to timely and effective communication about health and work issues”.
“What I am saying is not that there should not be a fee, but that the structure needs to be reviewed. I honestly feel that patients’ best interests are not served by grubbing about on fees for reports,” Grime says.
Whatever shape or form Black’s Fit for Work pilots eventually take, the role of primary care is going to be critical, he adds.
Another, more back-door way for OH to improve its relationship with GPs would be for more OH practitioners to work with GPs on providing occupational health to their practice staff, recommends Grime.
“OH could do more to provide tailored OH services for GPs and primary care staff themselves. It has been happening but at the moment it is fairly piecemeal. If GPs are shown the benefits of OH for themselves, it will help them to recognise the benefit of OH for everyone else too,” he says.
Darzi’s recognition that there needs to be more joined-up activity when it comes to return-to-work is valuable, points out Whittaker. One of the ongoing difficulties, for example, is that there are so many different budgets that often need to be brought together.
“Hospitals have separate budgets, PCTs and local authorities have different funding streams, so it is not a seamless service,” she says.
Similarly, schemes such as Pathways to Work already provide much that might be in a future template for a Fit for Work service but there is no overarching ‘glue’ joining everything together. “Government at a high level needs to be joining these things up,” Whittaker says.
Occupational health – with its experience of the employees and employers as well as its grounding within the health system – could be uniquely placed to act as a go-between between employers, healthcare providers and schemes such as Pathways to Work, she suggests.
“I would also like to see OH being brought more into primary care. At the moment there are no OH professionals to whom the jobbing public can be referred to,” suggests Whittaker.
“Unless someone has access to an OH department there is no seamless help that can be provided for that person. While someone is having rehabilitation, they should be being referred to OH who can provide support and get the ball moving, even if the initial referral was through primary care,” she explains.
What the Primary and Community Care Review recommends:
patients to be able to register online and have a greater range of options for consulting with their GP (for example by telephone or e-mail)
everyone with a long-term condition to have their own personalised care plan and those with complex health needs to have a ‘care co-ordinator’ by 2010
individual health budgets to be piloted to allow patients to have greater control over how NHS funding is used to support their care
creation of a secure web-based system called ‘myhealthspace’ allowing people to access and update their personal care record, share information with their care team, book appointments or order repeat prescriptions
faster access to community-based services such as minor ailments services and health checks in high-street pharmacies, walk-in services and self-referral to physiotherapy or podiatry services
identifying those most at risk of ill-health and offering early interventions that help keep people healthy for longer
piloting more ‘joined-up’ services to help people who want to return to work but are struggling with back problems, stress etc and
increasing access to ‘healthy living services’ making it easier for GP practices to refer or point people towards walk-in services such as exercise classes, stop smoking support or stress management.
What people said about the Darzi review
“The overwhelming majority of care provided by the NHS is safe, but the RCN believes the ambition now must be to drive up patients’ experience from a ‘safe’ to a ‘high quality’ service. If fully implemented, these recommendations have the potential to achieve this ambition.”
Dr Peter Carter, chief executive and general secretary, Royal College of Nursing
“We are delighted that the emphasis is moving away from patching people up when they are ill to promotion of healthy living and preventing illness so that we can help people stay as healthy as they can for as long as they can. The focus on the patient and the population that GPs serve is important. We believe that patients should have as much information as possible about the services that are provided because we believe in patient choice.”
Professor Steve Field, chairman, Royal College of General Practitioners
“This is good news for the health service and patients – putting the public right at the heart of a responsive and personalised NHS. This strategy presents opportunities for partners across primary care to work together to improve patient care and this is something that clinicians will be keen to engage with We support the idea of pilots of individual budgets for healthcare. There is much to be learnt from social care where direct budgets have been policy for some years but the take-up of these is still quite low.”
Bryan Stoten, chairman, NHS Confederation
“The emphasis on prevention and promotion work around mental health and the introduction of integrated return-to-work initiatives are hopeful signs that the NHS can be made to work alongside other agencies for everybody’s mental health. However, the current tiny amount invested in mental health promotion will need to be dramatically increased in order to realise Darzi’s vision.”
Dr Andrew McCulloch, chief executive, Mental Health Foundation
“Some of the ideas are not new – patients have always been able to consult by phone and practices have always been funded on the basis of the number of patients who are registered with them. Many of the ideas, such as personal plans for all patients, faster and simpler access to a wider range of community-based services and early intervention to improve the long-term outcomes for patients, are good and welcome.”
Dr Laurence Buckman, chairman, BMA GP Committee
“We’re particularly pleased that the government is sticking to its commitment to ensure everyone with a long-term condition is offered a care plan by 2010. Care plans play a crucial role in helping keep asthma under control and without one people with asthma are four times more likely to have an asthma attack resulting in emergency hospital treatment.”
Neil Churchill, chief executive, Asthma UK