“Disappointed”, “incredibly disappointed”, “deeply disappointed”, “short-sighted”, “sad”, “a great loss” – the response to the announcement in July that the Health and Work Development Unit (HWDU) is to close “in the near future” has certainly been consistent. Nic Paton investigates how this situation has come about and the ramifications for occupational health (OH).
The closure of the unit and its OH National Quality Improvement Programme (NQIP), a partnership between the Royal College of Physicians (RCP) and the Faculty of Occupational Medicine (FOM), raises a number of important questions for OH practitioners to ask, both of themselves and of their specialty.
OH response to the closure of the HWDU
“I was saddened to hear of the closure of the HWDU, which has made a tremendous contribution since its inception. Through its programme of national audits, development of evidence-based guidelines and supporting the implementation of NICE workplace guidance, it has greatly improved the quality of services delivered by OH services.
“Clinical audit and driving improvement must be a key strategic priority for occupational health if we are to improve outcomes and demonstrate our effectiveness. If the new single organisation becomes a reality, I hope that it will be able to develop a joined-up approach to addressing quality improvement so that this vital work is continued across all sectors of the occupational health community.”
Dr Richard Heron, president, Faculty of Occupational Medicine
“The demise of the HWDU is very short-sighted. The work it has done has contributed greatly to the efficiency of occupational health interventions, both in the NHS and elsewhere.
“The paucity of research funding, and the narrow academic base, in occupational health has meant that the work of Dr Williams and her team has been particularly valuable. It is to be hoped that the Future Hospital plan and the expansion of SEQOHS will fill the gap, at least in part.”
Professor Diana Kloss, chair, Council for Work and Health
“This is sad news as the HWDU has been an important centre of excellence for OH professionals. Its key functions of promoting occupational health evidence-based guidelines and clinical audit and quality improvement are central to effective OH practice. Its website has been a very useful resource for OH practitioners.”
Anne Harriss, reader in educational development and course director, occupational health nursing, London South Bank University
“I was saddened to hear this news. Clinical audit is the way that occupational health can measure the quality of the care we offer – if occupational health is to be taken seriously by other medical specialties it is absolutely vital that those of us working in the NHS are seen to participate in all of the elements of clinical governance. The NHS Health at Work Network board will be considering how the gap left by the closure of HWDU can be addressed in the future.”
Dr Anne de Bono, chair, NHS Health at Work network
“The closure of HWDU is a great loss to occupational health. Undertaking clinical audit is an important way for all of us – doctors, nurses and associated health professionals – to drive up the quality of our health and work services. Our practice is best informed by reflection and confirmed through regular audit both inside our individual organisations and across organisations; this is where the work of the unit was so valuable. I hope that with my colleagues at the faculty we can influence stakeholders to see the importance of this continuing in some way.
“We also need to have evidence-based guidelines funded and produced so that we are working to agreed standards. I will also be talking to the Department of Health about this at one of our regular meetings.”
Dr Alasdair Emslie, president, Society of Occupational Medicine
“It is disappointing, of course. The move to becoming self-funded was a huge challenge for what was a very small unit. I think there will, inevitably, now be a lull, but I am confident when it comes to health improvement the phoenix will rise from the ashes. My vision is that quality improvement becomes a key part of any future single organisation.”
Dr Sally Coomber, clinical lead, SEQOHS
As the unit’s clinical director Dr Sian Williams points out, it is ironic that the one unit carrying out national and evidence-based quality improvement work should be closing at a time when, since the Francis report on the Mid Staffordshire NHS Foundation Trust in 2013, the spotlight on performance and quality improvement within healthcare (and the NHS in particular) has never been sharper.
“But we are leaving a legacy, regardless of what is happening,” she emphasises. And it certainly is a valuable legacy. In its seven years, the unit has created a wide range of important clinical guidelines relevant to health and work, including in areas such as work and pregnancy, occupational asthma and dermatitis, among others. Crucially, through the NQIP and its implementation workshops, it has encouraged greater implementation of National Institute for Health and Care Excellence (NICE) public health workplace guidance within the NHS.
Indeed, as Occupational Health reported back in April, its second audit of NHS trusts measured how trusts were progressing on NICE guidance in a range of key public health areas, such as obesity, smoking cessation, physical activity, long-term sickness absence, promoting mental wellbeing, and the progress made since the first audit back in 2010.
A total of 73% of NHS trusts in England took part in the audit, representing 862,365 NHS staff, a hugely positive take-up rate.
There were two audit streams. One aimed to support the implementation of NICE public health workplace guidance in NHS trusts in England (mainly funded by the Department of Health) and the other was a programme of national clinical audits aimed at supporting quality improvement in OH care. The latter was initially funded centrally for NHS OH services, and then, when the funding ran out, launched on a subscription basis for all OH services, including other public-sector employers and the private sector.
The commitment of the NHS to the unit’s audit work has been “fantastic”, concedes Williams. Even with the financial constraints that the NHS is currently under, one-third of trusts that participated when the audit programme was free found the money to continue to be involved and engaged when the unit shifted to a subscription-based model.
“But the uptake from the non-NHS sector has been very disappointing. I sincerely hope that there is a major priority given to quality improvement, regardless of what the vote is around a single organisation,” says Williams, referring to the ongoing moves being led by the faculty and Society of Occupational Medicine (SOM) to create a single body to represent OH.
Williams is also at pains to recognise the financial commitment and support the unit was given by the college over the years, including, in effect, subsidising its financial shortfall for more than a year.
“The RCP has very kindly supported us, when that was never the intention. The idea was to move the national clinical audit to a subscription-based model. The president and other officers within the RCP have also worked really, really hard to try to change the mindset of organisations at a national level.
“But sadly there has not been the uptake or interest from the OH community that we had anticipated. I think as a specialty that is something we do need to reflect on,” she adds.
Against the backdrop of the current intense focus on audit and quality improvement, part of this reflection needs to be around what sort of profession and what sort of specialty OH and occupational medicine want to be in the future, Williams contends.
“Without [quality improvement], I think we as a speciality will not be looked at seriously. In fact, without it, can we even continue to be a medical specialty? The General Medical Council, for example, expects registered doctors to be carrying out continuous quality improvement,” she points out.
“So I think we need to look very seriously and consider our positions very carefully if we are not going to deliver the support and quality improvement activities. We are a small speciality and so I appreciate it can be difficult to fund high-quality national quality improvement programmes, but it is possible, and other specialties do it,” she adds.
One positive that the college has emphasised is that the closure of the unit will not mean redundancies. It has made it clear that organisations taking part in the NQIP will receive a full refund and have access to the webtool for data entry and reporting. The unit will also produce reports for any organisations that submitted data by 31 July, with the RCP waiving copyright on the audit tools to enable organisations to complete their audit cycle locally.
Another potential positive, as cited above, is if any new, single body for OH prioritises this area – and the comments made by new FOM president Dr Richard Heron and new SOM president Dr Alasdair Emslie do appear to suggest this is an issue on both their agendas.
A third potential positive, as Williams highlights, is the outpouring of support within the profession that has emerged: “Since the closure was announced I’ve received more than 150 emails, many of them from chief executives of national healthcare organisations as well as from participants. So the OH community has been very supportive.
“There have also been many emails from HR directors, some of whom have described what we did as a ‘sea change’ in their approach to staff health and wellbeing. So it is a huge disappointment,” she says.
Whether this “disappointment” will, in time, be looked back on as a hiccup or an interruption, in the progression and development of robust, evidence-based quality improvement or a long-term failure of commitment, is now down to the profession and specialty itself. There is, indeed, an important process of reflection ahead.