The annual conference of the NHS Health at Work network took place in Nottingham in September. In the wake of the Francis report in February – which criticised care standards – the theme was “Occupational Health – Good for staff, good for patients”. Noel O’Reilly reports on the link between the wellbeing of occupational health staff and the level of patient care.
NHS OH services have a central role in making the health service safe and sustainable and in delivering increases in staff productivity, Mike Farrar, former chief executive of the NHS Confederation, told delegates.
Farrar said that OH was key to deliver the cultural change demanded by the Francis report on the Mid Staffordshire NHS Foundation Trust, published in February 2013. At the same time, OH will have a role in delivering the 3% to 4% productivity increase needed to achieve savings of between £15 and £20 billion. These improvements are needed by 2013/14 to maintain the quality of NHS care, according to NHS chief executive Sir David Nicholson.
“[OH is] instrumental and fundamental in the NHS in delivering that financial challenge,” said Farrar. “The real resource you have if you are going to do things differently is people. When we’re financially challenged, it’s about people. If we get [OH] services right, the benefit of that is staff will feel more valued.”
Farrar added that there was a correlation between staff feeling valued and quality of care. He also mentioned the duty of candour referred to throughout the report, which aims to make the NHS more open and accountable.
He said NHS leaders had been too concerned with providing external assurances to inspectors and other external bodies before the Francis report, and that trusts would have gained more confidence if leaders had been more open about variations in NHS standards, including those within OH.
“There will be a legal duty on us to tell the truth,” said Farrar. “It’s a marker of that degree of confidence we’ve lost because of [the Francis report and other NHS scandals].”
A week after Farrar addressed the NHS OH conference, an MP health committee published a report demanding that the NHS went further than transparency on problems and introduced measures to prevent them occurring. Farrar said that the NHS was facing a cultural challenge: “How do we create a more engaging and transparent system? The only way we can do this is by hiring staff that go the extra mile.”
On managing clinicians, he said: “It’s not just about generating productivity, it’s about the role [OH has] in valuing people.”
In a question and answer session Farrar was asked if an increase in shift work and staff rotations could negatively affect staff morale.
He said the key was in engaging staff in the NHS through approaches that are designed to help drive cultural change such as the Listening into Action scheme: “It would be great if some of those staff got the chance to, say, redesign [OH’s] 24/7 processes, because that would be better than when people are forced into change.”
|The NHS Health at Work network|
|NHS Health at Work is a network of 130 occupational health teams dedicated to ensuring that the NHS has a healthy, motivated workforce that is able to provide the best possible patient care. The network represents 90% of NHS providers. Members work together to drive up the quality of services in the NHS. It also influences and advises government and other bodies about occupational health in the NHS and provides a gateway for businesses in the broader community that are seeking occupational health advice and support.|
Impact of staff health on patient care
Research suggests a strong link between the wellbeing of NHS staff and the quality of patient care, said Professor Jill Maben, director of the National Nursing Research Unit (NNRU) at King’s College London.
She said the “disturbing lack of compassion” shown by staff described in the Francis report is an illustration of how finance-driven health services with a narrow set of top-down targets can adversely affect patient care.
Researchers at the NNRU published a study on the English NHS (Maben et al, 2012a) that captured staff and patient views at team/unit level that, where possible, matched staff to the individual patients they cared for (Maben et al, 2012b).
In eight case studies across four trusts where patients rated their experience more negatively (older people’s care, acute admissions, the community nursing service and a rapid response team), researchers consistently found poor relational care and staff largely failing to “connect” with individual patients.
Staff spoke of high job demand and low control over their work, leading to emotional exhaustion, stress and burnout (Adams et al, 2012; Maben et al, 2012b). Some also spoke of bullying and an unsupportive work environment, which resulted in poor wellbeing at work (Maben et al, 2012b).
An analysis of the survey data revealed that both job demands and job resources (support at work) have a strong effect on wellbeing at work (Adams et al, 2012).
The analysis indicated seven staff variables linked to good patient-reported experience:
- good local (team)/work and group climate;
- perceived organisation support;
- high levels of co-worker support;
- low emotional exhaustion;
- good job satisfaction;
- supervisor support; and
- good organisational climate.
“If staff [feign kindness], they are more likely to become detached from other people – depersonalisation is most likely to reduce compassion and at worst inspire cruelty towards patients,” said Maben.
Referring to the Boorman report, NHS health and wellbeing review (Boorman, 2009), Maben said: “I wonder if we’ve lost some ground recently in terms of supporting staff. Personally, I’m not sure this report would be published in 2013.”
Maben is trying to get funding to evaluate in the UK an approach developed in the US at The Schwarz Centre for Compassionate Healthcare in Boston. It is based on one-to-one counselling, buddying, mindfulness and resilience courses.
“For me, it’s more about trying to create a job and workplaces that enable staff to give their best,” she said.
Ethics and governance in the NHS
All NHS trusts should take on the recommendations of the Francis report, a leading OH physician told conference delegates.
“When I read the Francis report, I thought you could strip out Mid Staffs; the processes apply to any organisation anywhere,” said Dr Paul Litchfield, BT Group chief medical officer and director of health, safety and wellbeing.
“The key to good governance is being good leaders. We all have to reflect on how we perform as leaders and how we can do it better. When things are running well, the politicians leave it alone.”
In a presentation on ethics in occupational health, Litchfield urged doctors and nurses to raise their awareness that “governance” is more than just “clinical governance”.
“Good governance relates to all aspects of OH. It also relates to the commercial aspects,” he said.
The ethics guidance of the Faculty of Occupational Medicine refers to company values and ethical codes, leadership and management. It also looks at involving the worker and extending the scope of OH from risk management to health and wellbeing advocacy and fitness to work.
The message is timely, given the shift from NHS Plus in March 2013 to the NHS Health at Work network and the creation of a not-for-profit social enterprise company entitled Syngentis.
The latter operates the Department for Work and Pensions funded Health4Work adviceline for small and medium-sized enterprises, offers clinical and business benchmarking tools and is looking to broker national contracts on behalf of the NHS for the provision of occupational health services.
“Customers can want OH to sign unethical contracts. If you compromise your ethical principles for commercial reasons you’re dead in the water… Don’t go for contracts where you don’t have the competencies or the capacity to deliver in a reasonable timescale,” said Litchfield.
The future occupational health workforce
The Council for Work and Health (CWH) is taking a leading role in evolving an OH workforce able to meet future needs. The CWH has set up the OH Future Workforce Project, which includes proposals for educating allied workplace health professions in OH skills.
The CWH is a multi-professional group that aims to ensure people of working age benefit from positive health results of employment and are not injured or become ill through work. It was set up after a recommendation in Dame Carol Black’s review of the health of Britain’s working-age population in 2008.
Its OH Future Workforce Project has identified the drivers of change as finance and commissioning, demographics, chronic and long-term conditions, technology, and education and training.
Professor John Harrison, who chairs the project, says that OH will need to change the way it delivers services to manage future workplace health issues: “In the future, the balance may change. For example, we may be more involved in supporting people with cancer so that they can remain in and return to work.”
OH may also need to extend services to people capable of working, but not in work. This could involve providing health information through technology, as well as face to face. A new paradigm for managing sickness absence management could also be developed, which would place emphasis on holistic approaches, including wellbeing and ill-health prevention.
“If we think we are going to carry on as we are, we are probably just deluding ourselves,” said Harrison.
The OH Future Workforce Project is developing a communication strategy to build alliances and further the aims of the project. The CWH is also looking at how later stages of the project will be funded.
The project is also working on defining roles for OH professionals and developing new training arrangements, and the most effective models for the delivery of services.
Discussions led by the Faculty of Occupational Medicine are taking place with Health Education England – which provides leadership for the new NHS education and training system – about creating a multidisciplinary College of Occupational Health and National School of Occupational Health. This organisation would have the power to validate postgraduate qualifications. Potential models for how the qualifications will work include peer-reviewed education modules for occupational hygienists that are linked to an international transferable qualification and the Chartered Society of Physiotherapists’ OH competency framework for physiotherapy.
“Over the next decade, we will see fundamental changes that will bring the training of OH professionals under one wing,” said Harrison.
The CWH is also supporting the development by physiotherapists and occupational therapists of an Allied Health Professionals Competency Framework for OH.
Harrison said: “I’d like to think over the next decade we’re able to recruit high-calibre professionals into OH.
“We will have the capacity to deliver what we want to deliver, and the competencies to do so. We will have proper talent management, and proper recruitment and retention programmes.”
Professor Diana Kloss, chair of the CWH, told delegates: “OH isn’t just about doctors and nurses anymore.
“People from different disciplines have got to be working together. And that’s very much the view of the Department of Health as well as the Department for Work and Pensions.”
Adams M et al (2013). “Catching up: The significance of occupational communities for the delivery of high quality home care by community nurses”. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine; vol.17, issue 4, pp.1-17.
Black C. “Working for a healthier tomorrow” – Dame Carol Black’s review of the health of Britain’s working age population (2008). Department of Health, Department for Work and Pensions.
Boorman S (2009). “NHS health and wellbeing – final report”. Department of Health.
Maben J et al (2012a). “Poppets and parcels: the links between staff experience of work and acutely ill older people’s experience of hospital care”. International Journal of Older People Nursing: Special Issue: Acute Care; vol.7, issue 2, pp.83-94.
Maben J et al (2012b). “Patients’ experiences of care and the influence of staff motivation, affect and wellbeing”. Southampton: NIHR Service Delivery and Organisation Programme.
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Source: Council for Work and Health