Improving occupational health services in the NHS

The framework for NHS occupational health provision is changing, and practitioners need to get involved, says Sarah Silcox.

The Department of Health (DH) has published a blueprint for the future of occupational health in the NHS in a move that is likely to produce a big shake-up of local services, including mergers and the creation of larger partnerships.

Occupational health in the NHS needs to play its part in meeting the £555 million target for productivity savings in the service by 2013, according to the “NHS health and wellbeing improvement framework” published in July 2011. The DH improvement framework is designed to support trust boards and senior managers in establishing a culture to support health and wellbeing in a sector that traditionally has struggled with higher-than-average levels of sickness absence and work-related ill health.

The improvement framework urges NHS employers to “use an NHS occupational health service [OHS] that offers a targeted, proactive and accredited support system for staff and organisations”. It adds that the current typical practice of allocating a budget for OH expenditure, which is simply rolled on year by year, has produced “mixed” results.

Realignment rooted in the Boorman review

The DH is urging trusts and other NHS employers to use more formal procurement processes for OHS in future by applying a set of minimum service levels. These core services – prevention, timely intervention, rehabilitation, health assessments for work, promotion of health and wellbeing, and teaching and training – are set out in separate proposals on realigning OH services (Healthy staff, better care for patients, July 2011). A realignment is necessary, the document suggests, in order to meet some of the concerns raised in the Boorman review of NHS workforce health published two years ago.

The latest proposals are likely to produce a shake-up in the structure and delivery of local NHS OH. The proposals accept that some existing OH services lack the scale necessary to achieve the full range of services envisaged, and will need to change.

In addition, the proposals require all OH services to achieve Faculty of Occupational Medicine (FOM) accreditation by 2012 (see box for details of specific accreditation requirements relating to NHS services). The DH expects procurement to take place across a number of services in future.

Scaling up

So how will NHS OHS respond, particularly given the new emphasis on becoming FOM accredited? Dr John Harrison, NHS Plus director, believes that some services will come together, using the resources developed by his organisation and NHS Employers, for example, guidance on procurement. His preferred model for delivery is the “area combined” method, in which OH services are provided over a wide area, but with clear accountability over delivery. Harrison cites the Avon Partnership in Bristol as an example of this model. This involves the OH services of three hospitals, each having flexibility over how they use joint resources and any operating surplus.

Alternatively, other individual OHS could become part of a managed clinical network, retaining their identity but agreeing on ways of working together. There will also be full-blown mergers of OHS, particularly given the financial situation in many areas of the NHS, Harrison predicts. Other services could become social enterprises along the lines of a joint NHS-local government service in Hereford, Harrison suggests. He adds that proposals for the reconfiguration of public health directorates could make this more likely, “which could be quite beneficial from an OH perspective”.

Harrison accepts that the March 2012 target for all OHS to gain FOM accreditation is unlikely to be met, but adds that more than 100 services out of 164 already had action plans by mid-summer, and that he expects around 50 or 60 to be fully accredited by the end of March 2012, which is “a huge achievement” given the preparation work required, particularly on evidence gathering, he believes.

Opportunity to re-evaluate

Dr Ursula Ferriday, chair of the network representing NHS OHS, believes that the proposals will not necessarily mean a broad scaling-up of delivery, but present an opportunity for her member services to re-evaluate operations and, in particular, to develop leadership skills.

She accepts, however, that the realignment proposals will lead to more collaborative and partnership working, but adds that “no one size fits all”. Those units based solely in one trust and not selling services externally will need to recognise that, in terms of their own development, there is “mileage” in linking with a larger, more robust provider locally, Ferriday adds. Some single-trust operations will be absorbed by larger ones, she believes; for example, if they are too small to offer all the services required to gain FOM accreditation, in which case they may be better off functioning as a satellite of a larger service.

Matching skills and tasks

The “Healthy staff, better care for patients: realignment of occupational health services to the NHS in England” document outlines the characteristics of a new-look OHS, including the need for it to contribute to improved organisational productivity. In particular, restructured OH services need to ensure that the skills of the whole team are used more effectively.

“OH is a multi-disciplinary service, and you need the right people at the right level doing the right tasks, not a mismatch,” says Harrison. For example, sickness absence management is an increasingly important part of the job and more assessments are now conducted by trained OH nurses, rather than doctors, with appropriate escalation where necessary.

The way in which employees access the OHS can be improved too, by using telephones to conduct basic assessments, for example. “This also improves efficiency, as the number of people failing to keep appointments drops if the contact is by telephone, yet the quality of the assessment remains high,” according to Harrison. Better use of OH technicians, for example, to take blood or test lung function, can also boost effective skill mix, he adds.

OH academic base “decimated”

The DH’s proposals call for the OH academic base to be strengthened, arguing that it has failed to develop in recent years, directly affecting OH in the NHS. Harrison agrees, arguing that OH academia has been “decimated” with the decline in the number of university departments: “If we lose one of the few left, we will be in a very serious situation.”

The proposals accept that the NHS is likely to become the main trainer of the next generation of OH professionals, again suggesting that the creation of larger units within the health service is necessary to enable the sub-specialisation required to perform a training function. But questions remain about the ability of the NHS to take on this primary trainer role, given financial constraints. “Developments now proposed in service delivery must not leave training behind,” Harrison believes.

NHS Plus is working with the FOM and nursing bodies on tools to develop the leadership skills of OH professionals in particular – for example, Harrison is organising a series of leadership events alongside the London Deanery this autumn.

The NHS OHS network agrees that the development of professionals’ leadership skills will be important in the new environment, and is building on the work already carried out by NHS Plus, including online tools for a new NHS health and wellbeing at work website.

Benchmarking and using data

The OHS blueprint states that clinical governance and OH audit is difficult in the NHS owing to the variability of data management across different services. Professionals need to produce management reports on the performance of their units and present this to a senior level in the organisation, using key performance indicators (KPIs). The data collected, argues the blueprint, should be used to monitor the activities and quality of the OHS and the care it provides, in addition to the actual health and wellbeing of the workforce.

The kinds of KPIs used to demonstrate the effectiveness of an OHS will depend on the contract or service level agreement in operation, according to Harrison, but NHS Plus would like to see KPIs developed around the six core services set out in the realignment proposals. NHS Plus is developing evidence-based clinical performance indicators, which will be launched shortly, for example, on the need for clear return-to-work plans as part of sickness absence case management.

The network chaired by Ferriday is producing a registry of practice in the NHS, which will serve as a benchmarking tool for its members. This will measure and record all aspects of practice in different OHS, for example, the time it takes to get an appointment, so that professionals can cross-refer their own practice. The registry should be produced by early 2012, according to Ferriday.

Delivery board

Feedback from members of the NHS OHS network to the realignment proposals has been overwhelmingly positive. Ferriday told Occupational Health magazine: “People see it as the right time to come together and stop working in silos. Now is the time to examine best practice and share it, working as a cohesive NHS provider, serving the whole country.”

Ferriday is chairing a new OH delivery board for the NHS, which includes representatives from NHS Employers, NHS Plus, as well as the staff side, including the Royal College of Nursing. The board’s first actions will be to develop an implementation plan for the realignment proposals and, in particular, to look at improving the commissioning interface between health and wellbeing providers and trusts through the use of service level agreements.

Mainstreaming OH in the NHS

The proposals for realigning OH argue that professionals need to engage better with stakeholders, including NHS line managers, boards and individual staff, in order to raise the OH profile and get the function onto high-level agendas. Harrison accepts that too often, OH operates “on the margins” and is not seen as part of mainstream healthcare, but as a kind of back-office management function.

Ferriday agrees: “OH professionals need to be knocking on the doors of trust boards and speaking to board meetings about the role that OH can play in achieving the improvements set out in the new framework.”

Harrision argues that OH professionals need to explain better their role in the context of their organisation’s broader wellbeing strategy. Boards, senior and line managers have to see how OH can improve health and wellbeing at the primary, secondary and tertiary prevention level.

“We need to persuade line managers that we understand where they’re coming from, and not give daft advice, but advice that is grounded in the organisation and its job role,” he adds.

OH is often hosted by, or seen as part of, human resources, which also has a mixed track record in the NHS. Harrison believes that it has taken Dame Carol Black and Steve Boorman to persuade boards that OH should be part of the core business, and adds that the latest proposals for realigning the service will drive this process further.

References

“NHS health & well-being improvement framework”. July 2011. Department of Health.

“Healthy staff, better care for patients: realignment of occupational health services to the NHS in England”. July 2011. Department of Health.

NHS occupational health accreditation
The Faculty of Occupational Medicine launched an accreditation system for occupational health providers on 1 December 2010. Providers of services to NHS employers are required to meet a number of NHS-specific accreditation levels, referred to as domain G, in addition to the general service levels.
Minimum requirements	Prescriptive evidence
Core services
The OH service (OHS) must be able to deliver each of six core services to NHS customers: prevention; timely intervention; rehabilitation; health assessments for work; promotion of health and wellbeing; and teaching and training.	Service level agreement (SLA), contract or other document describes an agreement setting out arrangements for each of the core services, or documentation to demonstrate that the OHS offered the services but the commissioner had declined them.
The OHS must review services with the NHS customer at least every six months.	Notes of review meeting with the NHS customer dated within the last six months, and documented amendments to the schedule of services applicable.
Business service levels
The OHS must cost services using a model that is reviewed or updated annually.	A current costing model or tool that covers the main areas of pay and non-pay expenditure should be produced. The tool should include an allowance for non-revenue generating time, for example, annual leave, and should allow for trust overheads and support professional activity. An OHS providing only in-house services must demonstrate it has costed its own provision to its host trust.
The OHS must have a business plan.	This may consist of a statement of planned activities and areas for improvement. The plan must cover at least a 12-month period, but not more than five years, and there must be evidence that the plan is regularly reviewed.
Delivery service levels
The OHS must offer dates for appointments within the timescales specified in the SLA or contract.	Record of an audit within the last 12 months showing mean waiting times.
The OHS must send reports within the timescales specified in the SLA or contract.	Record of an audit within the last 12 months showing the mean time for dispatch of reports.
Clinical service levels
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