The good news is musculoskeletal care for working-age people is widely considered a priority area by clinical commissioning groups, a government report has argued. The bad news for occupational health, however, is its conclusions that employers often try to do the bare legal minimum while OH provision itself is often fragmented and bedevilled by shortages of specialists. Nic Paton reports.
It may not have the snappiest title in the world, but the government’s report Understanding the provision of occupational health and work-related musculoskeletal services certainly does what it says on the tin.
The 51,000-word document published in May by the Employers, Health and Inclusive Employment Directorate (where the government’s Work and Health Unit is now located) sets out to evaluate the current occupational health market and, within this, the provision of services related to work-related musculoskeletal disorders.
While a standalone research document in its own right, it will undoubtedly feed into the work the government is doing ahead of the publication of its workplace health Green Paper, which in turn will set out the government’s response to last year’s consultation Health is everyone’s business: proposals to reduce ill health-related job loss.
For occupational health professionals, it also provides valuable insights into the state of, and appetite for, OH within the UK, especially how OH is commissioned, resourced and accessed, and the split (and some of the tensions) between NHS and private provision.
The research methodology comprised five main components. These were:
- a series of in-depth interviews with eight experts in the fields of OH and/or MSK, and a literature review;
- a semi-structured telephone survey of 103 OH providers;
- a further semi-structured telephone survey of 156 private and NHS providers that sell OH services commercially;
- a semi-structured telephone and online survey of 111 clinical commissioning groups (CCGs); and
- 15 in-depth qualitative case studies with OH providers and employers that had used their services.
‘Fragmented provision’ a legacy of 1948
Starting at the beginning, the report made the case that OH’s weaknesses go all the way back to the establishment of the NHS in 1948, and the decision at that time to leave OH outside the new national service. The NHS’s stance ever since, it argued, had “contributed to employment outcomes being largely overlooked in studies of health interventions and a lack of leadership in OH, resulting in fragmented OH provision.”
Since then, OH provision had gradually shifted from being primarily an in-house function to an outsourced model, mainly because of employers seeking to reduce costs. At the same time, outsourced private providers had generally been less committed to investing in the training of OH professionals, “and as a result the pool of UK OH expertise is perceived to be dwindling”, it warned.
The result was “uneven access to OH and work-related MSK services, a missing link between treating health problems and supporting individuals to work and OH not having been prioritised sufficiently by employers”. A bespoke OH and MSK offer fully-tailored to the employer’s workforce was nowadays “comparatively rare”, the report concluded.
Perhaps unsurprisingly, employers were the main commissioners of OH services: almost all providers (97%) had been commissioned by employers, it found. Around half (54%) of OH providers had also been commissioned by individuals, often self-employed individuals or those looking for work seeking mandatory medicals.
Nearly all OH providers (96%) said their support interacted with NHS provision, most commonly through employees going to their GP or being referred for specialist treatment. Seven out of ten (69%) OH providers captured data on the outcomes achieved through their support in all or most cases, with 56% doing so in all or nearly all cases.
Staff shortages, training and development
Virtually all OH providers (99%), again, did use some form of training, development or accreditation system, and the majority of these (96%) felt these were effective in ensuring quality of service. Six in ten OH providers (63%) did some form of marketing, mostly directed at employers (97%). Those who did no marketing (37%) did so because they felt they received enough business without it.
Most private OH providers, the report concluded, had only a small number of employees (17% were sole traders and 43% had just one to nine employees). The majority (82%) subcontracted work to additional members of staff on a regular ongoing basis.
On average, two-thirds (64%) of staff employed or subcontracted by private OH providers were medical professionals (such as doctors or nurses). The most commonly employed role was registered nurses with a SCPHN OH qualification, followed by occupational health physicians (OHP). Eight out of ten private providers (78%) felt they had the right balance of medical and non-medical staff.
Three-quarters (76%) of private and NHS OH providers conceded they did have access to funding for staff training. Among these, 61% partly or wholly funded courses. A third of (35%) funded training posts.
More worrying, just under half (44%) of private OH providers conceded they had roles they were unable to fill, most commonly OH nurse or physician roles, primarily because of a decrease in medical professionals with OH experience in recent years. In particular, registered nurses with a SCPHN OH qualification (51%), nurses with other OH qualifications (41%) and occupational health physicians (37%) were seen as the most difficult roles to recruit for.
Commissioning of MSK services
When it came to clinical commissioning group (CCG) commissioning of musculoskeletal services, nearly all commissioned MSK physiotherapy (99%), podiatry (97%), injection therapy (96%), joint replacement (95%) and specialist pain clinics (91%).
MSK physiotherapy was the most commonly used community-based MSK service among working-age people, with 88% of CCGs reporting it in their top three. Specialist pain clinics were the most commonly used hospital-based MSK service among working-age people (71%).
One positive finding was that MSK care for working-age people was widely considered a priority area by MSK leads in CCGs, with a quarter (23%) viewing it as “a very high” priority and half (50%) as a “high” priority.
Tailoring of MSK services to the health needs of the working-age population was widespread among CCGs, with 91% tailoring “to at least some extent”, and 70% “mostly” or “completely”.
Working-age patients were most commonly referred via their GP to both community- and hospital-based MSK services. Self-referral was also relatively common, particularly for community-based MSK physiotherapy.
The vast majority of CCGs (93%) reported at least some deliberate commissioning of MSK services to create a framework of multidisciplinary support for patients. However, these multidisciplinary services were not necessarily focused on employment needs or vocational rehabilitation, it was conceded.
Nevertheless, four-fifths (79%) of CCG MSK leads agreed their MSK services met the needs of local working-age people, although only 14% “strongly agreed”. This, the report argued, suggested there was “some scope for improvement”.
Is OH only for ‘enlightened employers’?
Given all this, what then does the report conclude? First, on commissioning, from the researchers’ conversations with the experts respondents the – arguably somewhat cynical – consensus was that health and safety legislation had, more often than not, “seeded the idea among employers that, as long as they are meeting their legal obligations, they don’t need to do anything else about employee wellbeing”.
The commissioning of more holistic OH provision had therefore become the province “only of more ‘enlightened’ employers”, they concluded.
Evidence from the polling of OH providers surveyed also largely supported this, the researchers argued. “They believed that employers and individuals are most commonly motivated to seek OH support by obligation, or reacting to issues affecting the business, rather than aspiration,” the report said, adding that improvements to productivity, health and wellbeing often “were secondary motivations”.
The majority of providers felt their service complemented NHS treatment or acted as a valuable follow-up to fit note advice. However, some did note resistance or delays when contacting GPs as, in their experience, “GPs did not consider OH a priority”.
Concerns about future capacity of OH
Perhaps the most concerning discussion, however, was around the OH workforce and, from that, the potential capacity of the profession to meet both current and future demand.
Given that, as already highlighted, most OH providers are small-scale businesses with relatively few members of staff and reliant on subcontracting out work, it is clear the sector’s capacity to scale up may be limited.
Yet, curiously, only a fifth of the providers polled said they were delivering services at full capacity. “In summary, demand did not appear to be exceeding supply, however of the available OH market capacity, 89% had been taken up over the previous 12 months,” the report concluded.
And then, as previously reported in Occupational Health & Wellbeing, there were real fears for the future of OH as the specialist expert at the workplace health table.
The report concluded: “Findings suggest that a potential large threat to the future of OH provision is the reduction of qualified OH physicians and nurses in recent years, which has led to unfilled roles for over two-fifths of OH providers.”
Providers were most likely to have vacancies in the most specialised roles, and these were also the hardest to fill, particularly nurses with an OH specialism. On top of this, there was a gap between the number of fully-funded training posts available and the number filled.
Feedback from the expert interviews concluded that, historically, major employers had provided a key source of specialist OH doctors, by recruiting GPs and training them to meet their business’s needs. But the past two decades of employer cost-cutting and outsourcing had hollowed out this model, leading to the warning that the available pool of OH expertise was “dwindling”.
“One expert suggested that specialist training within private OH provision was rare, and that they instead ‘poach’ NHS trained staff,” the report added.
Finally, on marketing, OH providers had limited need to use marketing to attract their customers, the report concluded. “Targeted marketing to specific sectors was rare, and a substantial proportion of OH providers did no form of marketing at all,” it argued.
- For those who wish to delve more deeply, the summary and full report of Understanding the provision of occupational health and work-related musculoskeletal services can be found at: https://www.gov.uk/government/publications/understanding-the-provision-of-occupational-health-and-work-related-musculoskeletal-services
Best practice case studies
The directorate’s report includes 17 case study examples of occupational health in practice, including anonymised employee stories, and the various lessons that can be learned from them.
These are split between examples of employers commissioning private providers, employer-funded in-house OH services, and NHS in-house OH services.
To cite just one to give a flavour, the report highlighted an employer that designs and manufactures military and industrial components and where the use of chemicals in production was a known risk but there were also issues around stress.
Originally OH provision had been delivered via telephone interview but the company then moved initially to a medical nurse being available on a daily basis and then, as it was felt the service was being misused, to contracting out to an OH advisor (a sole trader) working on site, with referrals available over the phone as well as face to face.
The referral process was divided into three parts: case management referrals for absence, health, and performance related concerns; surveillance for hearing tests, lung function tests, biological testing, support with training and policy development; business development for attendance management training and training to support a business with health-related initiatives. An electronic referral form through an encrypted portal was used to ensure data protection.
One production line employee, “Oliver”, was rushed to hospital with pain in his legs. His HR manager stayed in touch with him regularly and eventually made a referral to OH for recommendations for returning to work. As at this point Oliver was still physically unable to work, a second referral was made at a later point. The HR manager again remained involved throughout, along with the plant manager and line manager. The process took five to six months in total.
The OH advisor made a plan for a phased return and recommendations for a maximum number of hours and shifts, which the HR manager stuck to. Oliver was also made aware of Access to Work and helped him apply.
Other adjustments included additional breaks and being given the ability to sit down while at work. He was taken off night shifts as these were felt to add additional pressure. Oliver’s line manager felt the recommendations were communicated clearly to him.
OH’s role as a “neutral third party” meant the adviser had the authority to ask Oliver to return to work at a sustainable pace, the report concluded. “The HR manager believes Oliver otherwise would have risked returning to work too quickly, in order to prove himself,” it said
No sick leave had been needed to be taken since OH’s involvement, and the provider had also designed and delivered training for all managers on how to better support staff and reduce absence, it added.
‘How can we reinvigorate the OH market?’
The role of occupational health in supporting musculoskeletal health was highlighted by Dr Bola Akinwale, head of strategy at the directorate, at the Health and Wellbeing @ Work conference in Birmingham in March.
With coronavirus at that point still an emerging threat, Dr Akinwale stepped in at short notice to replace deputy chief medical officer for England Dr Jenny Harries, who had originally been scheduled to speak but was detained in London dealing with the response to the pandemic.
In her presentation, Dr Akinwale outlined how the government was committed to a gathering evidence around musculoskeletal health, including the role of the workplace, evidence around the role of physical activity in aiding recovery, and how healthy behaviours could be better promoted.
The government was, she emphasised, “working actively to try and think about how to smooth the interaction between different parts of the system that all play a part in health and work, both for people who are in work and out of work.”
She talked through some of the health and wellbeing trials and pilots going on around the country. This included the “Working Win” health-led employment trial in Sheffield that is using a modified version of Individual Placement and Support to try to assess the best type of support for those who are out of work, or struggling in employment due to health problems.
Dr Akinwale also highlighted the Employment Advisers in Improving Access to Psychological Therapies (IAPT) pilot, where more than 40% of IAPT centres now have employment advisers embedded within their services.
In discussing the government’s forthcoming workplace health Green Paper, Dr Akinwale said: “We know that there is a gradient in access to occupational health. So people who are working in smaller firms or smaller businesses are much less likely to have access to occupational health provision than those working in larger firms.
“One question is how can we smooth out that access; how can we reinvigorate the market so that there is both the capacity and the quality of provision that means that employers want to buy it, and understand what they’re getting?”
The role and use of fit notes was another issue that was firmly in the government sights, she confirmed. “Are some conversations handled really positively, with a positive outcome, so that the fit note isn’t necessary? Or is it that there are challenges in making a may be fit for work recommendation that doctors face?” she questioned.
“A big challenge is that GPs have seen a conflict between their role providing this statutory advice, which is somebody’s ticket to get SSP [Statutory Sick Pay] or claim benefits, that is one role, versus their role as patient advocate and their role in providing care. And that is a challenge to think about,” Dr Akinwale said.
“Understanding the provision of occupational health and work-related musculoskeletal services”, Department for Work and Pensions and Department of Health and Social Care, May 2020, https://www.gov.uk/government/publications/understanding-the-provision-of-occupational-health-and-work-related-musculoskeletal-services
“Health-led employment trial co-designed by University researcher launched by Disabilities Minister and Mayor”, University of Sheffield, August 2018, https://www.sheffield.ac.uk/news/nr/working-win-sheffield-launch-1.797917
“What might OH expect from workplace health Green Paper?”, Occupational Health & Wellbeing, April 2020, https://www.personneltoday.com/hr/what-might-oh-expect-from-workplace-health-green-paper/
“Employment Advisers in Improving Access to Psychological Therapies: process evaluation report”, Department for Work and Pensions and Department of Health and Social Care, July 2019, https://www.gov.uk/government/publications/employment-advisers-in-improving-access-to-psychological-therapies-process-evaluation-report
“Health is everyone’s business: proposals to reduce ill health-related job loss”, Department for Work and Pensions and Department of Health and Social Care, July 2019, https://www.gov.uk/government/consultations/health-is-everyones-business-proposals-to-reduce-ill-health-related-job-loss
“Staff shortages pose ‘large threat’ to future of occupational health provision, report warns”, Occupational Health & Wellbeing, June 2020, https://www.personneltoday.com/hr/staff-shortages-pose-large-threat-to-future-occupational-health-provision-report-warns/
“Occupational health to have ‘prominent’ role in fight against coronavirus”, Occupational Health & Wellbeing, March 2020, https://www.personneltoday.com/hr/occupational-health-set-to-have-prominent-role-in-fight-against-coronavirus/