Occupational health professionals face a challenging time in 2011. Nic Paton canvasses views on the future of the Black reforms and the impact of spending cuts.
April may be the cruellest month, but here’s hoping that for occupational health professionals it doesn’t live up to that billing this year. The reason that this expression could turn out to be true is that the end of March is the date when not only funding for most of the pilots testing national director for health and work Dame Carol Black’s workplace health reforms is due to come to an end but also when her own contract is up for renewal after her five years in the role.
In other words, there is a chance that, come the new financial year, the current climate of cuts and austerity could mean the hopes of the profession for a revolution in workplace health suddenly hitting the buffers at just the moment the person who has been the prime mover in effecting change disappears over the horizon.
Unduly pessimistic? Possibly. The problem is that no one – at least no one beyond the closed corridors of Whitehall – really knows what the plan is, or even if there is one. And with uncertainty comes worry.
As Mark Simpson, medical director at AXA ICAS Wellbeing, puts it: “While there has been no indication as yet as to whether or not she will be replaced, I do think that it would certainly be a negative signal if she were.”
Cynthia Atwell, recently retired chair of the Royal College of Nursing’s Public Health Forum, agrees that the uncertainty is focusing minds within the profession. “Whether the Dame Carol Black reforms will be continued, and in what guise, is still open to question. Every Government, after all, likes to put its own stamp on things,” she points out. “I would like to hope that Dame Carol stays in her position because she has been such a driving force and I do feel that it would be a shame to lose her.”
Concern about the future
Christina Butterworth, vice-president of the Association of Occupational Health Nurse Practitioners, hits the nail on the head by making the point that 2011 “is definitely going to be a crucial year”.
She adds: “My biggest concern is what is going to happen to the Dame Carol Black reforms, what is going to happen going forward.”
And Butterworth is not wrong about 2011 shaping up to be potentially one of the most significant years for the profession in a long time. Not only will it be crunch time for Dame Carol and her reforms, but NHS Plus will be in the midst of a major reconfiguration that could see it emerging as a very different beast (see box 1).
Occupational health could be at the sharp end of the reforms going on in the public sector and local government – traditionally one of the economy’s biggest “customers” for OH services – in the wake of October’s Comprehensive Spending Review with, again, the cuts and changes expected to start to bite from April onwards.
It that wasn’t enough for the profession to be thinking about, another key development for people to follow with interest throughout the year will be the Nursing and Midwifery Council’s review of the specialist community public health nursing register, which was announced in October.
Then there will be the matter of how the new OH accreditation scheme, launched in December, beds down and how (or if) it is embraced by employers and providers.
Simpson predicts that it could in time become something that is truly positive for the profession. “It is very practical and there is nothing within it that is unreasonable or unobtainable. I think that within three years it will be the de facto entry point,” he points out.
The Local Government Association’s Health, Work and Well-Being in Local Government report was carried out in 2009 and published in autumn 2010.
It analysed 10 case studies of local authorities running initiatives to promote employee safety, health and wellbeing in the local government sector, covering Burnley Borough Council, Conwy County Borough Council, Cumbria County Borough Council, London Borough of Enfield, Kent County Council, Nottingham City Council and West Dunbartonshire Council.
It found that councils were carrying out a very wide range of initiatives, including vouchers for swimming and exercise classes, health and wellbeing handbooks, stress awareness and smoking cessation activities, fitness challenges, return-to-work and rehabilitation activities, employee assistance programmes, health portals, manager risk assessment toolkits and so on.
Key lessons learnt from the case studies included:
The need to draw on staff expertise from across the authority and gain support of senior management.
The imperative of demonstrating a need for it, often through the use of sickness absence statistics or the argument that it will help meet local targets or corporate objectives.
The importance of using sickness absence statistics to identify target groups and causes of sickness absence and for the focusing of resources.
The challenge of how to target staff not located in central premises or who claimed to be uninterested in participating.
The importance of working within existing budgets as well as creative thinking around possible sources of external funding, such as partnerships with other local services.
How extending initiatives to family and friends can improve take-up and make staff more likely to take part in initiatives.
The importance of assessing the effectiveness of initiatives.
Review and reformation
When it comes to the NHS Plus reconfiguration, Dr Kit Harling, who stood down as chief executive in December last year, concedes that it is “not an ideal message and not one that people will probably be wanting to hear”. Posts will go and units and departments will be merged with the aim of creating a much less “fragmented” service.
He emphasises: “It is only now, with some of the pressures that are coming along, that people’s minds are focused and there has been a growing recognition that, yes, this fragmentation is something that has been inhibiting us in a fundamental sense.”
But, he stresses, rather than jobs going wholesale, for most people it will simply mean changes to how they work, although he admits that that situation is always unsettling enough.
“My gut feeling is that it is going to be more about restructuring and reconfiguring and taking out costs and duplication in the way people work.
“For example how we use IT is a huge problem – we currently have six systems or more that do not talk to each other. If we reduce the number of posts there is a chance to rationalise that and get the systems talking to each other so that we can routinely be collecting data and improving things.
“It is those sorts of things that are problematic more than anything else. I know people will find it difficult and have to work differently, but it should also be more interesting and exciting. Although we will lose some posts my feeling is that it will not be large numbers. But I do accept it is upsetting and makes people anxious.”
Within local government and the public sector (and indeed within the private sector), the new economic climate is probably going to mean having to embrace new models and new methods of service delivery, suggests Graham Johnson, OH nursing development manager for Bupa Health and Wellbeing UK.
He predicts: “The model of occupational health is going to have to change, and this is really forcing the issue. Existing in-house OH providers will have to start thinking outside the box.
“I can see the increase in talking therapies announced in the Comprehensive Spending Review leading to firms such as ours doing more health coaching.
“Nurses are going to need the motivational skills to argue their case. They will need to be creating an environment where they can provide the right support. But they may be under more pressure if they are also having to manage more people with chronic illnesses back into the workplace or support them to continue in work once they have made that transition.”
Steven Sumner, national health and safety policy adviser for local government body Local Government Employers, part of the Local Government Association, agrees with Johnson’s predictions. He says: “Within local authorities, there is already a feeling that they have been doing a lot with little money over a number of years. There is good, emerging evidence to suggest that for every £1 invested in health and wellbeing programmes at work there is a return of more than £3. Therefore, we encourage councils to invest in staff health and not cut back on these initiatives.
“This is not, after all, about Indian head massage or aromatherapy, though these interventions have their place, it is about supporting staff to make the critical decisions that will help them stay in work, stay productive and enjoy better physical and mental health outcomes.”
The organisation, for example, last year produced a report, Health, Work and Well-Being in Local Government (see box 2) that emphasised the value of occupational health and workplace health interventions within local government.
“It is clear local authorities will face a number of severe challenges in terms of how they deliver services or in deciding who delivers services on their behalf. But it is also clear that the only way they are going to be able to deliver or procure these reformed services is if they have a healthy, productivity workforce,” Sumner adds.
In fact, the priority that the coalition Government has given to welfare reform and getting people on benefits back into work could in the long run benefit occupational health, argues Atwell.
“Although there will be cuts in areas such as local government and other governmental organisations, there is maybe going to be a bigger role for occupational health, especially in terms of keeping people who are in work fit and healthy. If organisations want to have less absence then they will need to keep people healthy. So I still think there will be opportunities for occupational health,” she suggests.
“We do have to be positive and see the opportunities that are there. There may have to be changes and we may have to be slicker, smarter and better organised. It will be a question of working closely with businesses without losing our professional accountability,” she concludes.
The Future Configuration of NHS Occupational Health Services was carried out by OH nurse and regional Health, Work and Wellbeing “champion” Helen Kirk. It concluded that:
Current OH provision for NHS staff is highly fragmented and inefficient, especially in England, including the problems of multiple services in close proximity, services being provided at a considerable distance from the workplace being served and persistent difficulties of diverse IT systems.
Many NHS Plus tasks are straightforward and require either no, or very limited, specialist expertise, yet the skills-mix of OH teams does not always reflect this and there could be greater use made of OH technicians.
The future structure should be larger, geographically based departments providing services to a number of NHS employers, staffed by people with a better range of skills.
Keeping the workforce working
Sumner backs the philosophy of developing pilot schemes. He says: “As far as I can see, the new Government remains keen on the health, work and wellbeing agenda. It prevents people going on to long-term sick or employment and support allowance and possibly ending up as long-term workless. I think there is a recognition of the importance of workplace health and keeping people fit and healthy, especially when it is preventing people becoming chronically ill with the associated issues of sickness absence and lost productivity.
“I hope the Fit for Work pilots will continue and the best ones will be rolled out across the country. I understand that work is already under way across Government to identify the key themes to be reflected in the next five-year strategy for health, work and wellbeing.”
Some existing changes, such as the fit note, could start to gather more momentum and impact, according to Simpson. He says: “The fit note, I feel, has still not had the level of impact that it could do. The Royal Mail, for example, has been collecting data on how many have been issued within its organisation and has found it is less than 1%. So the message seems to be that GPs are just not signing fit notes.”
In this challenging financial climate, OH nurses will need to be setting out realistic priorities with long-term business goals, stresses Butterworth.
“We cannot afford to be too precious. We are few and far between and we are highly skilled; no one is going to replace us. But we also have to be collaborative; we have to be working with people,” she points out.
And maybe we need not be overly pessimistic about the prospects for this year, stresses Mairi Gaffney, head of the Scottish OH service Healthy Working Lives and OH representative on the Royal College of Nursing’s Public Health Forum. There is a good case to argue that the skills of OH nurses have never been more relevant to employers and the wider economy than they are now.
Making the case for the sector
“I think that OH nurses have really good skill-sets to help organisations in this difficult climate. We are the only group that has the knowledge and the skills to work within the workplace, with case managers and rehabilitation experts for example,” Gaffney says. “2011 will be a challenging year, of that there is no doubt, particularly within the public sector.
“Mental health issues, I suspect, are going to become much more important over the next few years.
“We may, too, have to change the emphasis of some of the work that we do and become more responsive to organisational needs. So there might need to be, for example, more of an emphasis on helping with workforce planning. Like everyone else I suspect we are going to be asked to be doing more with less.”