If the speculation is correct, the indications are that national director for health and work Dame Carol Black’s review into working health, and health minister Lord McKenzie’s review of vocational rehabilitation, could become two of the most important documents that the occupational health profession has seen for many years.
Although as Occupational Health went to press, neither had reported formally, it appears that Black in particular is poised to make some radical proposals, perhaps even going so far as to suggest that what the nation needs is a funded National Health at Work Service, not just a National Health Service.
Whatever their final recommendations, one certainty is that the capacity of the profession to meet the challenges set for it by the government – in effect to take up the baton that has been offered and run with it – is set to be an issue of fierce debate.
For a profession that is relatively small and which, even before the current focus, has had its own workforce problems of an ageing membership and rising workloads, the creation of any national service will pose huge challenges.
As Dr Sayeed Khan, chief medical adviser for the engineering and manufacturing body EEF, starkly puts it: “There are just not enough OH practitioners around. We have roughly about the same number of OH doctors and nurses as the Finnish. But they have a working population a tenth of the size of ours.”
With a disparity of this size, simply increasing the number of OH physicians and nurses is not an option (and would certainly not be a quick fix even if it happened). So the profession needs to start thinking about how this extra capacity can or should be achieved in other ways, he argues.
“Because we are such a small specialty, and the one for occupational physicians is even smaller, we really will need to think about smarter ways of working,” agrees Sharon Horan, professional nursing development adviser at the Royal College of Nursing (RCN).
Look around the workplace health landscape, and there are some obvious candidates for taking up some of the slack. GPs, occupational health technicians, health and safety practitioners (perhaps through the Institution of Occupational Safety and Health), possibly even community psychiatrists, could all have their role to play. And remember, too, that employers and line managers will need to become much better educated (workplace health as a core module of the MBA, anyone?) and do a lot less buck-passing.
But if this is the sort of road workplace health will need to go down, the competencies – the skills, the limits, the remit – of the individuals that are seeing, interpreting and treating ill employees becomes a central issue. Where should the joins be between the GP, technician or OH nurse, and when should each refer on to the other, and when should an OH physician come into play? How, too, should all this be communicated to employers without them glazing over?
“We need to be saying: ‘This is what you do, this is as far as you go and then the interpretation is done by the OH nurse’,” explains Warwick University’s Cynthia Atwell. “What it’s all about is knowing when to refer on, whether it’s a technician to a nurse, a nurse to a physician, or so on.”
This issue, if it has been addressed at all, has been done so in a rather piecemeal fashion, argues Geoff Davies, a director of the Commercial Occupational Health Providers Association (Cohpa).
“I do not think most people within occupational health are a long way apart in what they regard as being competent or not competent. But the problem is that it is not written down,” he points out.
Nevertheless, there are already documents and resources out there that could be drawn upon. The RCN has developed a competency framework for OH nurses (see box, page 24).
The Faculty of Occupational Medicine has drawn up a framework for medical undergraduates and the EEF and Health and Safety Executive in 2004 published a framework for physicians. NHS Employers has published useful guidance on developing a trust strategy for workplace health that also looks at competencies.
Employers such as Rolls-Royce and Unilever have gone a considerable way towards creating competency frameworks for OH technicians. And ironically, from having long played ‘catch-up’ in occupational health terms, the construction industry has also recently been setting an example when it comes to competencies.
In November, the Constructing Better Health programme unveiled a raft of new occupational health standards, giving employers benchmarks against which to judge their activities and performance.
The Nursing and Midwifery Council is also being urged by a new Occupational Health Training Competency Group – a consortium of commercially employed, NHS and independent OH practitioners – to clarify exactly what core competencies OH nurses should have now they have been moved on to the third part of the professional register.
Cohpa, similarly, is looking at the feasibility of introducing ‘levels of excellence’ to be awarded after a voluntary auditing process, argues Davies.
GPs are an obvious resource that could be better engaged in OH, suggests Khan. The government is currently evaluating the results of a pilot run last summer by the Royal College of General Practitioners (RCGP), in which GPs attended half-day workshops on occupational health.
The rumour is that the ministerial view so far is positive, and therefore it could lead to the programme being rolled out by the RCGP nationally.
“It is not about turning them into specialists or giving them any special qualification, it is about getting them to recognise that there can be side effects to issuing a sick note – such as being laid off or becoming unemployable – just as there are side effects for prescribing a drug,” says Khan.
“It is about ensuring that within that seven-minute consultation, the GP can assess how their health may be affecting their ability to work, and look at things such as dexterity and mobility,” he explains.
Of course, until now, GPs have mostly been pulled along this road kicking and screaming. So what is going to be needed, argues Khan, is a long, hard look at what will work as a driver for them.
“To me, it’s the RCGP. The bees’ knees would be if the college said that all 42,000 GPs had to go on a half-day course or some other training. If the college says they should do it, perhaps as part of their personal development plan, then it will happen. But I do not think the college will,” he says.
Just as the NHS has learned to embrace healthcare technicians, so it makes sense that, given its more front-line health role, OH will need to make much greater use of OH technicians, argues Horan.
“Healthcare can be very protectionist and isolationist. We do not like to give anything away to anyone else. But now we need to be showing a united front, both doctors and nurses,” she says.
Atwell agrees. “We need to take off the blinkers and look at why we are doing what we are doing. There has got to be a big culture change for the whole medical and nursing profession. We have to have standards of recognisable training for everyone, and which people understand.”
There are different skill sets required for GPs, health and safety practitioners, line managers and so on, agrees Caroline Whittaker, senior OH lecturer at the University of Glamorgan, which now offers OH courses for technicians.
“There are, for instance, more confidentiality issues around health and safety practitioners because they are not under the same strict guidelines that we are. So it is about people working together and getting to know each other’s skills,” she says.
“I see OH technicians doing some of the things that OH nurses used to do, screening, audiometry and so on, and in the process freeing OHNs to look at the more strategic issues,” she adds.
It is important to remember too that, while clinical standards are important, OH is unlike other healthcare professions in that it needs to relate to and communicate with employers and employees, stresses Davies. Therefore, practical commercial standards need to be a part of the bigger picture.
“You could send a technician with a mobile screening unit to a construction site,” he says. “But what do they do if they find three tests are abnormal? They are not qualified to interpret it or speak to the workers about it, so do you simply leave them very frightened for a week? If an OH nurse was there, they could have talked about it to them. But then that is a commercial issue as a provider.
“What you might do is send a technician to the site, but then have a nurse go down at the end of the day to talk through any abnormal readings,” he adds.
Cohpa is sceptical that a central, NHS-style OH service is the answer.
Davies worries it would be too unwieldy. Rather, what employers would probably prefer is simply an “OH Google”, he says, a central, high-quality information and advice database or portal, something Cohpa already offers, albeit on a small scale.
“If it was a free service for employers and gave them a list of all the accredited providers in their area, their qualifications, key performance indicators and how to review what they are getting, that would be great,” Davies argues.
“There is also need for incentives for employers. It is far easier for them to let go of someone rather than keep them in work, if it is a lower-level type of job,” he adds. “Some employers consider it is a hassle and too expensive to rehabilitate them and, at the end of the day, money talks.”
Of course, all this talk is fine in principle, but who should lead this process and bring all these disparate strands together? An obvious candidate would be the Health Work and Wellbeing strategy’s National Stakeholder Council (NSC), Horan says.
“Everyone appreciates the fact that we need to be thinking outside the box and looking at the whole spectrum of nursing. We need to be having those conversations about how we are going to get people back into work,” she says.
Atwell says: “If the NSC agrees that it is the way it needs to be, then we need to get all of the profession involved and look at these areas and what we need to focus on.”
“We need to break down the barriers between doctors and nurses, between who does what,” she adds.
As Khan points out, change is coming whether the profession likes it or not. “I can see a situation where OH technicians are doing the donkey work, health and safety practitioners are doing the non-clinical work, and OH physicians and nurses are doing the higher level clinical stuff.”
And, while change can often feel threatening or uncomfortable, it is infinitely better to be driving change than having change done to you. Khan says: “People will feel that their territory is being eroded, but times change. General Electric boss Jack Welch used to say: ‘Control your destiny, or someone else will’.”
Royal College of Nursing’s competencies framework
The Royal College of Nursing’s Integrated Career and Competency Framework for Occupational Health Nursing, published in 2005, could yet become a blueprint, or at least a starting point, for a wider competency framework for the profession as a whole.
The framework helps to set and agree best practice and competence as well as pay levels. It is also a handy tool for employers to gauge what level of qualification is appropriate for the job, a key element of the current debate over competencies.
The framework splits OHNs into three categories:
A ‘competent’ OHN is a first-level registered nurse with two years’ post basic experience, plus post-basic education and training equivalent to a university diploma. Such a nurse, it argues, will work under established protocols and procedures at operational level. They will require support of more experienced practitioners for non-routine decisions and defer to an experienced or expert nurse, OH physician, line manager or HR for support in more complex occupational health issues.
An ‘experienced’ OHN is someone with at least two years’ experience in an OH setting and post-basic education and training equivalent to a university degree, and will hold or be working towards a recordable OHN qualification with the NMC. At this level, they are expected to be able to develop and establish protocols and procedures at operational level and develop and lead on safe and competent practice. They are be able to work autonomously and, where appropriate, seek support and guidance from an expert nurse, OH, line manager or HR.
An ‘expert’ OHN is someone with at least five years’ experience in an OH setting, post-basic education and training equivalent to university higher degree and with a recordable OHN qualification with the NMC.
They develop, lead and establish protocols and procedures at operational and strategic levels, innovate, develop and lead on safe and competent practice, and lead and develop consultant occupational nursing and consultancy.