Health reforms special report: The Black review one year on

Once-in-a-generation opportunities, by their definition, do not come along that often. So, for occupational health professionals, the fact that there has been so much activity around workplace health in so many areas over the past 12 months, in the wake of national director for health and work Dame Carol Black’s ground-breaking Working for a Healthier Tomorrow blueprint for the future of workplace health, is encouraging. The fact that so little of it is being led by occupational health nurses is less so.

In fact, ever since the government unveiled its response to Dame Carol’s review in December 2008, there has been an intensity of activity around workplace health unlike anything we have seen in years, as Dame Carol herself points out.

“When you think that as little as four years ago none of this was happening, it makes you realise the long way we have come already. It is really very exciting,” she explains to Occupational Health.

Fit for Work Service pilots, a fit note due imminently, a review of workplace health in the NHS completed in six months, a mental health at work strategy unveiled, the launch of a small businesses OH helpline, new OH standards – the list goes on.

“I am extremely pleased with the progress so far. The important thing for me has been that the government has not withdrawn any of the funding it put aside, despite the recession. They could have said this was a ‘nice to have’ but not essential. But they did not,” adds Dame Carol.

For OH nurses, however, the worry is whether, yet again, the ‘Cinderella speciality’ is being left behind. OH practitioners will have little input in the Fit for Work Service pilots and were overlooked when regional health, work and wellbeing co-ordinators were recruited – a role that Dame Carol herself had suggested could suit OH well. Even the Council for Occupational Health, as originally proposed, has had its name changed to the Council for Work and Health.

So, has OH been marginalised? No, stresses Dame Carol, although it could be doing more to lead the agenda and share best practice.

“OH has had the most wonderful opportunity to show how good it is. Until this energised activity got people interested in health and work, it was often a minority specialism and often ignored,” she says.

“It should show some leadership and take the baton and run with it, and in part it has done that. There are very good examples of OH professionals around the country doing fantastic things, and the faculty (Faculty of Occupational Medicine) has responded really well and moved very quickly to create new standards,” she adds.

The progress made so far has been “astonishing”, agrees Dr Sayeed Khan, chief medical adviser to the manufacturers’ body the EEF.

He, like Dame Carol, is confident a change of government this year (of whatever hue) will not lead to the reforms unravelling.

“We are too far ahead with it now and worklessness would be as much of an issue for a Conservative government too. If anything, Dame Carol’s £100bn estimate for the cost of sickness absence was probably conservative, so would a future administration undo what has already been done? I don’t think so.”

The expertise OH can bring to the table is immense, so practitioners need to be making themselves indispensable.

“Occupational health is now broader than it has ever been. It may be that OH professionals need to be positioning themselves as offering the higher level, specialist advice,” Khan suggests.

Whatever happens within the wider workplace health landscape, OH nurses are going to remain “absolutely essential”, agrees Dr Tony Stevens, president of the Society of Occupational Medicine.

“They are the one thing that, at the end of the day, are not tradeable. I think occupational health will find its place in the new order, but I think it may have to keep a much closer eye on what is going on in GP practices,” he adds.

What is also very clear is that while 2009 set the cogs in motion, both 2010 and 2011 will be the years when the hard work of making Dame Carol’s vision a viable, permanent reality gets done. Against that backdrop, there is still time – probably – for OH to make its voice heard.

“It has been fantastic to see things develop and I think this coming year will be the one where a lot of these things come into full swing and we will be able to see how they are going to work or whether they will need adjustment,” says Dame Carol.

Here’s an outline of progress so far.

The fit note

The replacement for the Med3 sicknote remains on track for a 1 April 2010 national launch. The new note will require amendments to the Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) regulations, though that is expected to be a formality, even with a general election looming. Of greater concern is the lack of information in the public domain about the note.

“Even though it is supposed to be coming in from April, what it will look like remains a mystery,” says Dr John Canning, chairman of the British Medical Association’s Professional Fees Committee.

“We recognise the fundamental principle that work is, by and large, good for people, but the problem we have is that this is often something that leads to confrontation within GP practices, which can be stressful for both sides,” he adds.

There is still disquiet among many GPs that they will be being expected to pronounce on an area – a patient’s ability to work – in which they do not feel qualified.

For most employers who don’t follow these things closely, its arrival could be a big shock, warns Dudley Lusted, head of corporate healthcare development at AXA PPP healthcare.

“The government has been committed to it for some time, yet there has not been one single piece of corporate communication about it to employers. It is going to happen in just four months and, if nothing changes, a lot of employers are definitely going to be surprised,” he says.

“At the moment, the problem is GPs signing people off sick too readily. With the fit note, the danger is the reverse will happen and employers will suddenly be having to deal with people turning up to work and being required to make adjustments or accommodations,” he adds.

However, according to Dame Carol, advice and guidance is currently being worked on by officials – and so the picture should be clearer by April.

The Fit for Work Service

How this will look and work became much clearer in October when the government announced the 10 sites that would be piloting the various delivery models.

Most of the pilots are getting under way proper from this month onwards and will be running until March 2011. There will be models looking at supporting people who are struggling to remain in work because of ill-health, people who can be helped back to work, and people who do not have access to other specialist at-work health support.

While the lack of OH leadership has raised eyebrows, with most pilots being led by local authorities and PCTs (though one is being led by an NHS Plus team), for Dame Carol, access to OH as part of the Fit for Work case management approach will still be vital. “OH is going to be one of the very important spokes that feeds into the hub,” she says.

The National Strategy for Mental Health and Employment

Unveiled in December, the government’s new National Strategy for Mental Health and Employment includes a tripling of funding for research into mental health, from £50m a year to £150m.

Its three-pronged strategy includes a pledge to establish a network of mental health co-ordinators in every Jobcentre Plus, the unveiling of a national OH helpline (see below), and an examination of how the Access to Work scheme could be extended to people with mental health conditions, to help them get and stay in work.

The strategy has urged GPs to do more to raise the issue of depression and refer people on to specialist services if need be, with a new training programme to be designed by the Royal College of Psychiatrists to help give doctors more confidence on this. Officials have also suggested people on benefits could eventually self-refer to cognitive behavioural therapy services.

The national OH helpline

This was unveiled by the government in December alongside the mental health strategy (see above).

The helpline is being run by NHS Plus in conjunction with NHS Direct and will start being promoted to businesses from this month, using organisations such as the Federation of Small Businesses and the British Chambers of Commerce. Posters are also set to be distributed to GP surgeries.

The intention is threefold, explains NHS Plus programme manager Keith Johnston: to help people stay in work and not take time off, to help businesses help staff back to work, and to improve the productivity of businesses.

“It will be focused on employers that have fewer than 50 staff, though we will not turn away those with up to 250 employees. It will also be able to respond to calls from individuals and employees,” he says.

It is being piloted in seven regions of England: East Anglia; Merseyside; the North East; the North and West Yorkshire; Portsmouth, south Hampshire, East Sussex and the Isle of Wight; south Buckinghamshire, south Oxfordshire and west Berkshire; and west London. There will also be pilots running across Wales and Scotland. The pilots will run until at least March 2011 and will be evaluated by the Institute for Employment Studies.

Businesses or individuals will be able to access the advice line online at or through NHS Direct. If they are not located in an eligible postcode they will be transferred to their nearest NHS provider but if eligible (and ringing within office hours) they will be put through to an OH adviser.

“They will be OHNs and there will be a dedicated phoneline into each department. Some units have recruited extra staff hours but we will have to see how it develops. It may be that it is mixed in with existing work. But the critical thing is to ensure the call is dealt with by a qualified OH adviser,” explains Johnston.

“They will be able to give advice on areas such as sickness absence, attendance management, MSDs, mental health and health surveillance,” he adds.

The government has decided it will now be tested solely as a free service, rather than testing a paid-for variant alongside. NHS Plus has also been working to develop ‘partner relationships’ with, for example, Citizen’s Advice Bureau, for callers with questions about debt or employment or legal issues, explains Johnston.

“Similarly, if an employer requires specialist mental health support or physiotherapy, or something like that, then the unit can signpost that employer on to the relevant specialist services,” he adds.

The Council for Work and Health

Originally envisaged as a Council for Occupational Health, the change of name during last year was made to reflect the breadth of its membership and the need to have a title that was easily accessible, says Cynthia Atwell, chair of the Royal College of Nursing’s Public Health forum (which has replaced the Society of Occupational Health Nursing forum).

“We felt quite strongly that we needed to have a much broader remit, and the term occupational health is still not all that well understood, whereas work and health is,” she says.

The council has now met three times and is chaired by lawyer Diana Kloss, with Dame Carol attending as an observer. It is very much a multi-disciplinary body, incorporating representatives from occupational therapy, physiotherapy, ergonomics, counselling, psychology, health and safety, general practice, occupational medicine and the private sector, as well as OH.

“What I most want out of the council is for it to get people out of their different silos, to get people to work more together and break down barriers so that there will be more effective team-working,” explains Dame Carol.

The council is in the process of producing employer-friendly guidelines on professional qualifications, for example, explaining what an OH nurse actually is and does, or a physiotherapist and so on. It is also working on drawing up a discussion paper on the future of OH education, as well as looking at the issue of what the health needs of the working population are likely to be like over the next 10 years.

“I would like to think that in 2010 there will be as much progress made as there has been in 2009,” adds Atwell.

National GP training programme in occupational health

Backed by £2m of government funding over three years, this was the programme piloted by the Royal College of General Practitioners in 2008 and now being rolled out across the country, with the first sessions running from June last year.

So far, according to the EEF’s Khan, some 40 sessions have been completed and around 1,000 GPs offered the training.

While the intention is not, and has never been, to turn GPs into OH specialists, “what has been found is that confidence in dealing with these issues went up markedly from before to after the workshops”, explains Khan.

“All these initiatives are inter-linked. You will have the SME helpline, for example, helping people, which will in turn link to the fit note, which will link to the Fit for Work Service and greater recognition by GPs that they can do things themselves, such as use talking therapies and so on,” he adds.

The intention is that around 150 workshops will be run in total, with between 3,000 to 4,500 GPs receiving training.

Health, work and wellbeing co-ordinators

For OH nurses, the recruitment of regional health, work and wellbeing co-ordinators over the summer and autumn left a bitter taste in the mouth.

Despite having been identified by Dame Carol as the sort of role in which OH nurses could potentially make an impact, the roles were largely filled by civil servants after very little external publicity, in a process described by occupational medicine consultant and OH columnist Dr Richard Preece as “a missed opportunity”.

While acknowledging the disappointment that some in the profession still feel about this – and stressing that the roles are fixed two-year contracts and so are only first appointments – for Dame Carol the key is now for the profession to work with those who are in post. “If you look at the people who have been appointed, I think they are all certainly very capable of doing this job,” she says.

And, according to Khan, it could have been less conspiracy on the government’s part to overlook OH and more simply the difficulty of communicating effectively with a profession that does not have a single voice or leadership.

“Someone should have spotted it and raised the alarm. But who do the government agencies go to talk to about occupational health, the AOHNP, RCN, Society of Occupational Medicine and so on?” he points out.

Creation of new guidelines, standards and OH accreditation

Even before the government had published its response to the Black Review, movement was under way on the creation of new standards and guidelines for OH, explains Paul Nicholson, project lead at the Faculty of Occupational Medicine and chairman of the British Medical Association’s Occupational Medicine Committee.

Stakeholders, including representatives from the Royal College of Nursing and the Association of Occupational Health Nurse Practitioners, employers’ bodies such as EEF and the CBI and trade unions, were invited in August 2008 to join a working group, which met for the first time that October and led, in June last year, to draft standards being published and a formal consultation. This in turn led to a second draft being published in November, with the final version set to be unveiled later this month.

The standards have been being piloted at 17 OH services, NHS and military, with pilots looking at relevance, ease or difficulty of gathering evidence to show you meet them. The standards cover minimum requirements for providers in areas such as business probity, information governance, employment and people, facilities and equipment, relationships with purchasers and relationships with workers.

The next stage from here is to develop an accreditation system, something expected to be unveiled this time next year.

“We have already started to have meetings with accreditation bodies. Organisations that have established systems and record-keeping will probably meet the system, but the key is that we have got to show it will be credible but also robust and affordable,” says Nicholson.

Review of workplace ill-health within the NHS

Now better known as the Boorman Review, after its author Dr Steven Boorman, the final report was published in November, with the government accepting its recommendations in full.

The report called for a shift within the NHS towards a preventative approach to staff health and wellbeing, greater accountability among senior managers for the health and wellbeing of staff, annual assessments of NHS performance in this area, and more early interventions for staff to deal with musculoskeletal and mental health problems.

It also said NHS trusts would now be required to undertake risk assessments on staff health and wellbeing, a process that could lead to the remodelling of OH departments. It recommended the drawing up of nationally agreed service standards for early intervention services, for which the government has set aside £6.5m.

The Business Healthcheck Tool

Originally launched in the summer of 2008 by Dame Carol and Business in the Community as an online tool to help businesses, particularly SMEs, estimate the cost of absence within their organisation, the Business Healthcheck Tool has for much of the past year dropped off the radar for a very simple reason – it didn’t really work.

“The first prototype had quite a lot of things that needed to be improved. Many businesses that tried to do it found that unless they were very well-informed computer-wise, it was not easy to do,” concedes Dame Carol.

The tool has been taken back to the drawing board, re-trialled, and is now close to being relaunched, probably in March.

“The NHS has expressed a desire to use the tool as part of its response to the Boorman Review and we also now have SMEs involved. The important thing is to get it right,” she adds.

The National Centre for Working-Age Health and Wellbeing

This has been, as Dame Carol concedes, the initiative with perhaps the lowest profile. “Of all the programmes this is now the one we are concentrating on. We have the key objectives developed and are in the process of putting that together, but you cannot create the centre until you have done quite a lot of the other things,” she points out.

The intention is for the centre to act as an observatory that gathers, collates and analyses evidence with regards to working age and health and wellbeing, identifying and monitoring trends in the health of the working-age population and building up an authoritative evidence-based database.

The next stage is for the running of the centre to be put out to tender, a process that was expected to start either just before Christmas or early in the New Year. The probability is that the centre will end up being located within an existing, similar organisation, will be staffed by a core team and then supported by remote partners.

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