NHS Plus Conference: April 2010, Coventry

An NHS Plus Quality Strategy has been launched setting out standards for policies and procedures for occupational health (OH) teams and introducing compulsory accreditation for all members of the network by 2012.

NHS Plus has also asked the NHS Wellbeing Scrutiny Group to consider requiring that all NHS occupational health departments are accredited in future.

“Historically, membership [of NHS Plus] has been equated with those OH services that want to trade externally,” Professor John Harrison, clinical lead OH service standards for accreditation, Faculty of Occupational Medicine (FOM), told delegates at the NHS Plus conference in April.

“We believe time has moved on from that. We’re now in a position where fundamental to being a member, NHS Plus will be the equality agenda and the accreditation process, so that NHS Plus becomes a kitemark for quality for all OH services across the NHS.”

Harrison said the standards did not mean services needed to be identical. “We’re moving to a position where we’re developing a common model of OH provision in the NHS, which the NHS Plus board is keen to support. That doesn’t necessarily mean that all OH services are going to be the same, and we wouldn’t want that,” he said.

The standards were developed in response to recommendations in Dame Carol Black’s review of health and work and Dr Steve Boorman’s review of the health of NHS staff.

Audits of depression screening and management of back pain among NHS Plus members in 2008 and a benchmarking survey in 2009 demonstrated a need and desire to address variations in services, including waiting times, response times and use of clinical audit.

“I think Steve’s [Boorman’s] report is about organisational change and we don’t want to do a few health promotion activities and tighten up our sickness absence,” said Harrison.

“It is more fundamental than that. There’s a great opportunity, a pressure wave has built up enthusiasm and we can capitalise on that. The Boorman report is the start – we’ve got our act together and we have to deliver.”

Accreditation will be based on the standards launched by the FOM in January, with the formal launch of the accreditation process expected by the end of this year. Ongoing costs of accreditation are not yet available.

NHS Plus director Dr Kit Harling told delegates that keeping costs down was a “moral imperative”.

“Getting people prepared for work, support through transition beyond that – it doesn’t take a specialist nurse of doctor to do that. We need to think about how to deliver the service and go for the minimum cost option consistent with quality.”

Harrison said that one way to cut costs is to reduce unnecessary duplication, for example in pre-employment health screening. “The answer is that we don’t trust each other,” he said. “Do we believe that our colleagues at St Elsewhere are incompetent? If we don’t I suggest that we are being self-indulgent. We have to look carefully at our behaviour and ask ourselves what are we here for, who are the people we serve?”

A range of support activities will be put in place until March 2012, including local briefings, the appointment of local facilitators, and local workshops.

Services that are not ready by March 2011 will be supported until assessment in March 2012. After that, the strategy says: “NHS Plus membership will expire after a set period of time in the rare event that formal external verification is not completed within an agreed timescale.”

NHS Plus will also establish an Expert Clinical Governance Steering Group to support the strategy, and a programme of clinical pathways to include infectious diseases, musculoskeletal, mental health, workplace assessment and pre-employment support.

“We hope this is based on what you [NHS Plus members] see as the way forward,” said Harling. “This is a process, this is not an end. We can adapt, change, develop, but we have to start somewhere.”

York NHS Trust backs OH

“You can’t measure occupational health in terms of cost, you have to measure it in terms of value and quality,” according to York Hospitals NHS foundation Trust chief executive Patrick Cowley.

“OH is an essential input in developing the best quality health services – keeping people in work and fit. You are part of the team that provides healthcare. The reason OH is successful in York is that it has a profile, the team is motivated and passionate about what they do, business-like, resourceful and accountable,” Cowley added.

He said that the effectiveness of the trust’s initiative to tackle long-term sickness absence helped make the case for a range of OH services. “That gave us confidence to invest. You have to find a way of breaking into that cycle. The board wasn’t interested in how much it was costing, but how we could continue to make best value of that investment.”

York’s OH strategy was updated in 2009 to increase health promotion, smoking cessation support services and stress counselling.

Boorman urges occupational health to speed up

The author of last year’s review of the health of NHS staff applauded the quality model being introduced by NHS Plus, but urged practitioners to speed up in implementing his recommendations.

“The one thing you’ve got to do is be willing to speed up,” said Dr Steve Boorman, director of corporate responsibility and chief medical adviser of Royal Mail.

“It’s right to be thinking about what the ideal model workforce looks like and it’s right to be working out a quality framework at the moment. But don’t take too long about it and don’t take the time to design it perfectly and get it 100% right, because by the time you deliver it, it’s too late.”

He said his recommendations were backed by health service finance and HR directors, and if OH did not deliver then they would turn to other providers to implement his proposals. “If you don’t take that opportunity, then they’ll do something else to move it on because they’ve committed themselves to do something on it and they won’t wait,” Boorman warned.

He said that OH needed to get better at demonstrating the impact of the service on patient care. “All this stuff about being embarrassed about employing physiotherapists and fast-tracking waiting lists and making a business case for making an intervention for NHS staff… If you effectively link it to the quality that patients get in a shrinking investment scenario in the NHS moving forward, you’re in a different ball game.”

He said that NHS Plus could take a lead in improving standards of service nationally and in lobbying for resources. “The opportunity of NHS Plus is for you to have the debate and speak with one common voice. Behind the scenes there is disagreement. That makes it difficult for your voice to be heard at the top table. A lot of the models you’re delivering to are based on history and the ball game is changing. OH has got to significantly change and up its game.”

He called on OH departments’ “market successes” to share good practice across the NHS. “How do you bottle that and how do you use it in terms of marketing more widely? You’re got to be up for it in terms of making it happen. The attention could be dangerous for you. Unless you grab that opportunity with both hands you might get left behind, and that’s dangerous because you are the experts and specialists at delivering what you do.”

He admitted that his report was produced quickly and its academic rigour could be challenged. “But it is the best picture we’ve got at the moment and it has done what we wanted to do; to make the case for change and a change that’s been accepted,” Boorman said.

He warned that if NHS managers put too much emphasis on achieving the £555m sickness absence cost savings identified in his report, there could be an increase in presenteeism, where staff go to work when they are sick. “OH is not about attendance management. It’s not about getting the sick back into the workforce, because that will screw the quality standards at the end of the day.”

Expert says there is no depression epidemic

Despite reports to the contrary, there is no great epidemic of depression, according to a review of the evidence by Dr Max Henderson at the Institute of Psychiatry at King’s College, London.

Henderson’s research identified problems with diagnosing depression in general practice and a steep rise in prescriptions of anti-depressants over the past decade. He advised OH practitioners to ask employees questions to identify depression, about whether they are receiving treatment, adhering to treatment, if it is evidence based, if it is working, and if the patient understands the length of the treatment.

Examples of accreditation delivery standards

  • Pre-employment health screening (paper): 80% within two working days

  • Appointment with specialist nurse: Within six working days from referral

  • Telephone enquiries: Response within four hours

  • E-mail enquiries: Response within one working day

The NHS Plus Quality Strategy’s five-stage model

  • Identify and develop explicit standards to ensure quality of care

  • Develop care pathways designed to provide optimum interventions

  • Develop training and support to ensure local implementation

  • A system of accreditation will ensure compliance

  • Regular reviews of standards to ensure relevance

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