A cloud hovers over occupational health sustainability due to an ageing workforce and service users’ reluctance to fund the education of younger recruits. Elizabeth Preece asks if the apprenticeship levy offers a silver lining.
We must consider the sustainability of occupational health if we are to have skilled clinicians and academic staff to provide quality services and develop the next generation.
“Sustainability” often conjures up thoughts of “being green” or of corporate social responsibility, but perhaps for those working within occupational health it’s more about finding a balance.
The Brundtland Commission (1987) provides the most widely accepted definition of sustainability as “meeting the needs of the present generation without compromising the ability of future generations to meet their own needs”.
Giselle Weybrecht (2010) describes it as having “never been about getting things perfect…(but) about getting people to engage, to do something, to get started”.
Sustainability can be described as having three pillars, which represent the areas of economic, social and environmental development.
Workforces, including that of OH, are part of the social pillar. We need to consider how this generation can conduct itself, without adversely affecting the next generation. The next generation needs to be trained and available in sufficient numbers to undertake the work required of them, and the next generation in turn must have the capacity to train the following one.
Challenges for today’s occupational health services
OH is a unique speciality, with services delivered collaboratively by doctors, hygienists, ergonomists, nurses, physiotherapists and others. These services are not presently part of the “free at the point of delivery” NHS provision, so employers are required to pay for them.
This brings into play the economic pillar of the sustainability model. OH services need to be financially viable for companies or organisations, and equally OH departments need financial resources to maintain and sustain their workforce and infrastructure requirements.
Awareness of health hazards in the workplace has eradicated or reduced a number of traditional occupational conditions. However, workplaces must continue to respond to evolving health hazards.
Although it is widely acknowledged that good work is good for health (Waddell and Burton, 2006), the health of the workforce continues to provide challenges for employers. Demand for OH services continues today, but with new priorities. Changing demographics, an increase in retirement age, mental health concerns and long term conditions have led to a paradigm shift within OH, but not a let-up in demand.
The occupational health workforce of today and tomorrow
Although the demand for OH services continues, there is significant concern that today’s skilled and experienced workforce is reaching retirement age faster than new practitioners are being trained to take their place.
An All-Party Parliamentary Group Report (2016) on the medical workforce crisis identifies a perfect storm that looms over the coming 10 years as there is such a high proportion of doctors in OH aged over 50 years (64%). Recruitment of doctors to the speciality has been falling since 2003. The report shows the number of training posts is at an all-time low and half the long term average. The (already small) number of specialists fell by almost 5% during 2010-13 alone (GMC, 2014).
The call has gone out for an increase in training places, to meet demand now and in the future, as well as strategies to encourage doctors with skills and knowledge to remain in employment. There are further plans to raise the profile of OH within undergraduate medical students to attract more trainee applications.
However, we still await the response and longer term support to meet these requirements and to fulfil the aspirations of Dame Carol Black’s (2008) Review of Work and Health in Britain and the more recent Green Paper on work, health and disability (2016).
The situation within OH nursing is only marginally better than that of physicians. The nursing workforce also has an ageing demographic profile. Over 50% of OH nurses are over 50 and just 4% are under 35 years old (Coomer and Ballard, 2016).
Employers are already having difficulties recruiting suitable candidates. It is estimated that about twice the current number of qualified OH nurses will be needed to deliver a quality service for the future (Council for Work and Health, 2016).
Reasons for the sustainability crisis
The causes of this skills crisis are multi-factorial and complex. OH, as a speciality, does not have a high profile although it may punch above its weight in terms of value added to the UK economy.
Many undergraduates and graduates are unaware of what’s involved in OH or how to carve a career within it. As a career option, it is not well marketed, which needs addressing.
Having students spend time in OH would provide exposure and a level of understanding about the role not currently available to many. However, this requires a deeper training culture to be embedded within OH departments and there is little current evidence of this happening.
Placements for those studying for OH qualifications are challenging to find, so a paradigm shift is needed to ensure undergraduate students gain access to OH experience. Collaborative working may be a strength in OH, but training the next generation doesn’t appear to be.
Perhaps this is a consequence of the business context. Whether working within the public or private sectors, OH departments tend to be run on similar business principles.
Occupational health as a business
The UK’s business culture has traditionally focused on the financial bottom line which means the delivery of OH services has been aligned with the requirement to make profits.
Public sector departments, including in the NHS, have often acted on similar principles. Supporting the next generation is not financially advantageous so has not been part of the business plan, sometimes despite employed practitioners’ enthusiasm to address the issue.
Practice teachers’ accounts of supporting students in their own time and potentially with travel costs met from their own pockets are not unusual. Where is the employer support and long term vision regarding the future workforce?
The next generation
Perhaps users of OH services have not been encouraged to consider educating future practitioners as part of their role or as an ethical responsibility. Users of the diminishing resource of skilled OH practitioners have some thinking to do.
There have been champions of training for both OH doctors and nurses, within the private and public sectors. The NHS, the armed forces and some notable large companies and private providers have been committed to training the next generation.
Businesses are increasingly aware of their ethical reputation and to need to look beyond the profit imperative in response to changing public demands. The millennials are making their presence felt and the need for companies to become more ethically aware is unlikely to diminish with the coming generation.
Is the future of OH an ethical issue?
Negative media coverage of companies such as motor giant VW, because of the diesel emissions scandal, and cafe chain Starbucks, in relation to tax avoidance, has forced them to change. While Starbucks did nothing illegal, the company had not acted in accordance with publicly acceptable behaviour.
Healthcare has a strong history of ethical practice dating back to the Hippocratic oath, and codes of practice enshrine standards of conduct. Business ethics is a developing area which has evolved under the umbrella of corporate social responsibility.
Linda Fisher Thornton (2013) provides useful insight into ethical leadership, describing the domains for consideration as lenses through which we can view decisions (see table).
The profit motive needs therefore to be in balance with concern for legal requirements, the purpose behind business activities, and the impact on the people involved and the wider community. Then there is the wider remit, preserving the planet and the legacy for coming generations.
Although OH service users have met legal health and safety and employment law requirements, there is no statutory requirement for employers to support the development of the next generation of OH specialists.
But have employers succeeded in balancing the need to make a profit with improving the welfare of the community and leaving a positive legacy? Is there a responsibility, particularly for the larger users of this scarce OH resource, to at least contribute to its sustainability and the training of OH specialists?
Many companies use public or private sector OH providers, who may employ a large team of specialists. Some providers have a good history of training new specialists, others less so, perhaps because training activities bring in little revenue.
In the same way that supply chains are managed within industries for a range of environmental and social concerns, so too could the tendering process for contracts include a requirement to contribute towards developing the next generation of OH specialists.
A role for everyone
Health Education England (HEE) has the role of ensuring the healthcare workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place. However, the OH workforce is diversely spread across sectors.
HEE, and the National School of Occupational Health (NSOH), which sits within HEE may come to oversee the training of doctors and potentially nurses in the future. However, this needs to be delivered in partnership with all those who use the skills of OH practitioners. That is, of course, if they wish to act in an ethical manner.
Is there a cloud hanging over some larger companies or organisations who require or use OH services? They may not have considered their responsibility to educate the next generation because specialist practitioners have until now always appeared from the goody bag of the NHS or other willing sources.
In addition, for many who may have wished to contribute something, it can be hard to know what to do if unable to manage a comprehensive training package. OH educators perhaps need to consider innovative ways to engage with willing partners.
The new apprenticeship levy
Perhaps just as this challenge is reaching a crisis point, the new apprenticeship levy could offer a silver lining. Both public and private sector organisations whose payroll bills exceed £3m per year must pay 0.5% into the apprenticeship pot.
While £3m sounds high, when it comes to payroll, as any larger employer knows, it doesn’t go far. Just 100 employees, with an average salary of £30,000 will take an organisation to the threshold. The government estimates 22,000 businesses will be affected (Personnel Today, 2016).
Apprenticeships indicates to many people the idea of young workers entering the workplace, but this money can be used to fund training for the established workforce, and at higher levels.
The report by the NSOH (2016) recommends consideration of apprenticeships as a training pathway for future OH nurses. Work is under way, in collaboration with the NSOH to explore and develop the mechanisms for this to be one pathway to the development of practitioners for the future.
The apprenticeship scheme links OH as a speciality to OH service users and provides a mechanism for larger users to contribute to the sustainability of the speciality, by using some of their levy pot.
Apprenticeships may not be the perfect solution to the perfect storm facing OH provision, but they are a way to meet Weybrecht’s goal of not making things perfect, but of getting started and encouraging engagement in addressing the future OH skills base.
All Party Parliamentary Group (2016). Occupational Medical Workforce Crisis. Online.
Ballard J, Coomer K. The state of OH nursing: A national survey of occupational health nurses. Occupational Health at Work 2016; 13(3): 17-28.
Dame Carol Black (2008). Working for a Healthier Tomorrow: Work and Health in Britain. Online.
Brundtland Commission (1987). Our Common Future. Online.
Council for Work and Health (2016). Planning the Future: Implications for Occupational Health delivery and training. Online.
Department for Work and Pensions (2016). Department of Health. Work, health and disability: improving lives. The Rt Hon Damian Green MP, and The Rt Hon Jeremy Hunt MP.
General Medical Council (GMC) (2014). The State of Medical Education and Practice in the UK. Online.
National School of Occupational Health (2016). Training, Mapping the landscape: Informing the Future. Online.
Personnel Today (2016). How will the Apprenticeship Levy Affect Employers? Online.
Thornton LF (2013). 7 Lenses: Learning the Principles and Practices of Ethical Leadership. Richmond. Leading in Context LLC.
Waddell G, Burton K, (2006). Is Work Good for your Health and Wellbeing? Online.
Weybrecht G. (2010). The Sustainable MBA, A Business Guide to Sustainability. 1st ed. Chichester: Wiley.