NHS PLUS UPDATE the honest broker?

GPs may not like it, but for years they have operated as the NHS’s de facto OH service. Not for NHS workers, of course, but for every sick employee dragging themselves into their surgery, citing back pain, stress or whatever it is that is stopping them heading into work.

The NHS has a vast pool of OH expertise at its fingertips. There are around 220 OH departments in 650 trusts, with many more buying in services from specialist providers.

But when it comes to spreading OH expertise – whether NHS-based or commercial – to a wider audience, particularly smaller and medium-sized business, the figures do not make happy reading.

The government’s public health White Paper Choosing Health, published last autumn, estimated that OH provision for these sorts of businesses was often as low as 6% and down to around 2% for micro companies.

But it was also very clear that, when it came to improving the health of the nation at work, OH was one of the key tools available to employers, but one not being used nearly enough.

Which brings us neatly to NHS Plus, the network of NHS-based occupational health units established to provide OH services not only to NHS staff, but also to the private sector.

Set up in 2001 by then health secretary, Alan Milburn, the idea was for NHS Plus to become a money-making venture for the NHS and be a first port of call for businesses with a workplace or OH issue that needed to be addressed.

It was predicted there would be ongoing contracts with employers, links between different units, and NHS OH practitioners would get valuable exposure to the commercial world.

The problem, as Occupational Health reported back in September, is that thus far, NHS Plus has proved to be anything but a roaring success.
According to NHS Plus chief executive, Kit Harling, fewer than half of the 220 NHS units had so far signed up to NHS Plus. Other observers and practitioners pointed out that there was little awareness of it among employers and little incentive to promote it among OH practitioners.

Where NHS Plus work from employers did come in, it was often one-off management referral requests, with some units reporting fewer than five NHS Plus referrals a month, and sometimes none, said practitioners.

Equally damning, few businesses, according to the Institute of Directors, rated the service, with just 10% saying the advice they got was ‘good’ and 60% describing it merely as ‘adequate’.

Yet, while its track record may leave a lot to be desired, all the evidence points to the fact that ministers are still committed to it and, in fact, want to see NHS Plus playing a much bigger role in the future.

Choosing Health, for instance, makes it clear that while commercial providers have a role to play in widening OH take-up, there is a real case for the NHS, through NHS Plus, shouldering a greater part of this burden.

“Research shows that, although its [NHS Plus’s] work has grown at a rate of around 20% a year, more needs to be done,” it stressed.
“We will increase the availability of NHS Plus services in parallel with the development of occupational health services in the NHS,” it added.
Alongside this would be the development of evidence-based guidelines on OH and the development of ‘measures’ to ensure that services were of a consistently high standard, said the Department of Health (DoH).

You also only have to look at last year’s NHS Improvement Plan – the health service’s ‘five-year plan’ – to see that NHS Plus is viewed as a hugely important tool in terms of bringing rehabilitation and OH services to a wider audience.

As the document states: “Building on the role of NHS Plus, the NHS can play an increasingly vital role in ensuring that employees are able to return to work as soon as possible following illness or injury.

“The Department of Health will work with the Health & Safety Executive and the Department for Work and Pensions to ensure that a wider occupational health approach is supported by the NHS,” it added.

Harling and civil servants in the DoH and the Department for Work and Pensions (DWP) have long recognised that the existing NHS Plus structure is not working and cannot remain as it is.

Last summer, in evidence to the House of Commons Work and Pensions’ Select Committee, which was investigating the working of the Health & Safety Executive (HSE), Harling argued that the HSE had now recognised the scale of the problem it and others faced in terms of workplace health.

“The next step,” the committee recorded of his evidence, “was to move to ‘actually implementing some positive policies that are going to help the delivery of occupational health care in its broadest sense’.”

The fact that health and safety had been so closely linked over many decades had led to a false assumption that the systems for managing the risk of accidental injury and occupational disease were similarly identical, when in fact they needed a different approach, Harling told the MPs.
What was needed was “a multifaceted approach” based on “the development of partnership working”.

At the same inquiry, Simon Pickvance, of Sheffield Occupational Health Advisory Service, stressed the need to get away from primary care as having to act as a “default occupational health service” role, for which it was ill-equipped.

Another issue, he argued, was that there was “no secondary referral service for OH problems from primary care”.

In other words, patients could be referred to consultants, who could deal with symptoms, but, unlike OH practitioners, they were not trained to look for causes and whether there were factors at work causing something to happen. This again, could be something that NHS Plus could help to tackle.

So, where is this all leading? Harling, for one, has suggested one answer might be to do away with NHS OH departments in England all together and create instead a network of 10 to 12 regional OH services, so giving the service more clout within the NHS.

Now, however, an alternative model appears to be gaining ground, too. Although details remain sketchy, it is thought ministers are leaning towards the idea, probably sometime this summer (and assuming Labour wins any general election), of spinning off NHS Plus from the health service completely.

Rather than being within an organisation within the NHS, it would become a stand-alone, not-for-profit body, with the secretary of state for health as its sole shareholder.

Employees would be retained on their NHS terms and conditions and, as a separate body, it would have a higher, and much more defined, profile; it would no longer just be seen as ‘part of the NHS’.

As well as helping smaller businesses to reduce absence, the move is understood to be linked to the government’s drive to get more people off incapacity benefit and back into work.

January and February saw a flurry of announcements to this end, key to which is the expansion of the pilot scheme Pathways to Work, which offers people on the benefit access to personal advisers, NHS rehabilitation, and links with voluntary and private sector advisers.

This in turn is being seen as a key part of plugging the UK’s skills gap and so improving economic performance, while at the same time reducing the cost of the welfare state.

Harling, for his part, has told OH that he is unaware of any plans to spin off NHS Plus from the NHS. Ultimately, whatever the future structure of NHS Plus, or indeed NHS OH services as a whole, the key, as the MPs on the committee, the DoH and the DWP all agree, is that both NHS and commercial OH services need to have a much higher profile if workplace ill-health is going to be tackled more effectively.

Similarly, employees do not want to be put in a situation where they have to talk about health problems with an employer, when the problems are potentially work threatening.

In its response to the work and pensions’ committee’s report, the government said the HSE was exploring two ways of encouraging employees to feel able to speak to their employees about factors affecting their health.

“The first is by testing proposals for an occupational health and safety support system. This would provide access to a ‘problem solver’, who can give independent advice on work-related issues to both workers and employers,” it suggested.

“The second is an initiative to encourage greater worker involvement in identifying and tackling work-related health and safety problems,” it added.

“Within all this, NHS Plus may have an important role to play as a provider where capacity is available and it operates with the range of skills needed to tackle modern work-related health issues,” it concluded.

And it is this, perhaps, that gives the clearest indication of where NHS Plus, whatever the future of its management structure, is likely to be heading.

If NHS Plus can become an independent, trusted and, most of all, credible ‘third party’, then it will be filling a hugely valuable role.

OH prides itself on its independence and on maintaining patient confidentiality, but there can still be, often quite unjustly, a lot of suspicion among employees about its role and relationship with employers.

Through the use of the trusted NHS brand, NHS Plus may not necessarily need to provide all the services all of the time, but it could develop a niche as the ‘honest broker’.

Succeed in that, and the days of the primary care-based ‘default occupational health service’ might, thankfully (for both GPs and OH practitioners), be numbered.

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