Pluses and minuses

NHS Plus was launched in 2001 to help tackle the dire shortage of OH provision among small and medium-sized businesses (SMEs). Three years on, has it made a difference? By Nic Paton

NHS Plus was unveiled to the world at the London School of Economics in March 2000 by then health secretary Alan Milburn. In many ways it was an apt venue to choose. After all, here was a service that was going to be launched with the express purpose of tackling what is, even now, the woefully poor uptake of and interest in occupational health by small and medium-sized businesses (SMEs).

The TUC, for one, has estimated that fewer than one in three workers, under 7 million, have access to employer-funded occupational health services. The figures are even worse for small and micro-sized firms, some just 34 per cent and 13 per respectively, providing any form of OH service.

So when Milburn said he wanted to create “a portfolio of NHS occupational health services, which can then be bought by employers to improve the health of their employees”, it certainly seemed like a laudable goal.

NHS Plus was to be, and effectively now is, a network of occupational health services based in NHS hospitals that could provide OH services both to NHS staff and sell services to the private sector.

Businesses have access to a dedicated website, where they can tap in their postcode to find the nearest NHS OH provider that is signed up to NHS Plus and then approach them for help and advice.

NHS chief executive, Sir Nigel Crisp, added flesh to the proposals, saying the idea was a “splendid opportunity” for chief executives to raise the profile of OH both within and outside their trusts.

What’s more, there might even be scope for NHS Plus to become a money-making venture, he predicted, and trusts could find themselves in the pleasant position of needing to take on more occupational health staff to carry on this lucrative outside work.

Firms with a national presence, it was hoped, would use NHS Plus services around the country, agreeing ongoing contracts that linked together different NHS units. This in turn would help NHS OH staff to share best practice, while at the same time gaining valuable exposure to the commercial world.

The problem is, four years on, for most occupational health practitioners and, indeed, most businesses, NHS Plus has proved anything but as popular, cash-generating or, even as economic, as was hoped.

“NHS Plus has progressed, but not as much as I would have liked it to, not as much as it could do,” admits NHS Plus director, Dr Kit Harling, former director of occupational health at Avon Partnership NHS Trust, who is now seconded to the Department of Health.

And the experience of Angela Perry, manager of Nottingham Occupational Health, is pretty atypical of practitioners working with NHS Plus.
Perry’s team has been offering commercial services through the NHS since 1989 – well before NHS Plus got off the ground. But, even though she embraces the concept, she concedes she gets on average fewer than five NHS Plus referrals a month, and sometimes none.

“Most of the NHS Plus work that comes through is one-off management referral requests. And there is a high expectation that we can turn it around the same day,” she explains.

What referrals there are will generally be from smaller businesses – 500 staff or fewer – which simply either cannot afford, or are not interested in, ongoing contracts. “That bit of it has really ground to a halt,” she says.

And while Perry agrees that doing work in the commercial sector can be good experience for her team, the NHS Plus side of the service can hardly be considered a cash cow. “It would be difficult to say the income is significant,” she says.

A business manager with an NHS OH unit in East Anglia, who did not want to be named, agrees.

“Most of our work is localised. We have about 200 business contracts, but we do not have any contracts where we link up with other sites,” she explains.

“The concept, as we understood it, was to make it much broader. They wanted it to be used by multi-site companies that would then link up with other OH services on different sites. But that has not happened.”

Nevertheless, companies that do come forward and make an approach often welcome the advice and help they get; advice and help they would not have been able to afford through an in-house occupational health department, she concedes.

One of the problems for many OH NHS teams, argues Perry, is that they are often working from relatively cramped premises and physically there is not the space to take on the commercial work, even if the demand was there.

Similarly, most NHS OH practitioners recognise they have their work more than cut out meeting the ever growing demands of looking after the health and welfare of their own NHS staff, employees who, perhaps inevitably, take precedence in their minds.

If NHS staff do not exactly appear to be singing its praises, the views of businesses about NHS Plus are just as worrying.

A survey by the Institute of Directors late last year found that just 10 per cent of 285 businesses polled rated the information and advice they got from NHS Plus as ‘good’, with 30 per cent actively rating it as ‘poor’ and the rest, with somewhat faint praise, citing it as simply ‘adequate’.

By comparison, independent OH providers got a 40 per cent ‘good’ rating, 50 per cent ‘adequate’ and just 10 per cent ‘poor’.
Report author, Geraint Day, argues it is a cultural thing: businesses do not believe an NHS-led service can ever truly understand the demands and constraints of commercial businesses.

“When NHS Plus was set up, there was a feeling that it was being a bit ambitious, given that the NHS had not universally been seen as an exemplar in this area. It was felt that if it could not look after its own workforce then what hope someone else’s?”

He adds: “Historically, too, quite often the NHS has talked quite a different language to business.”

For NHS Plus’s Harling, the problem is the quality and reach of NHS OH services as much as the language they use. Of some 220 occupational health departments in 650 trusts in England, only about half have so far signed up to NHS Plus.

He also points to a National Audit Office report earlier this year that branded NHS occupational health services as ‘patchy’ and ‘variable’.

“If we are going to do anything to take forward NHS Plus, then the NHS OH services have to be sorted out first,” he argues.

Even where units do make any money out of NHS Plus, the grumble is that it simply disappears into the trust’s coffers, so removing any incentive there may have been in the first place, he adds.

“I am quite happy with NHS Plus as a brand name, but I do not see setting up a separate NHS Plus structure as being remotely desirable,” he says. “What we have got to do is address the issue of how occupational health is provided within the NHS.”

The answer, he suggests, is a radical one. For the past nine months or so, Harling and other civil servants at the Department of Health have been beavering away on an idea to do away with individual NHS OH departments in England, and instead create 10 to 12 ‘super’, regional OH services.

While still only at the idea stage, Harling argues passionately that a regional structure would give NHS OH practitioners much greater clout in the constant battle for more funding and more recognition within the service.

“At the moment, we have 220 entirely unlinked occupational health departments, ranging in size from two people in temporary accommodation to teams with 60 staff. Is that really the best way do it? The answer, of course, is no, it is not. Regional services based within a geographical area are probably the way forward in my view,” he says.

OH practitioners, instead of being employed by individual trusts, would become part of these much larger, regional teams.
This would give them a much greater profile within the NHS. Instead of being a small part of a disparate organisation, and managed as such, within a regional framework the sole focus of their employer would be OH. It is also likely there would be more scope for professional and career development, to specialise and move around, Harling argues.

While the idea still needs to get ministerial approval, and Harling is keen to stress it is by no means a certainty that it will happen, informal talks have already been held with various interested bodies, including the British Medical Association, NHS Confederation and health-related trade unions.

“Most feel that the status quo is not desirable in the long term. Most people I have spoken to are keen on the change. I have been surprised and encouraged by the enthusiasm that people have had,” he explains.

From the point of view of NHS Plus, if there was a regional service there would be no reason why NHS Plus should not continue as before. “I do not see any reason why a regional NHS service should not work outside the NHS,” he says.

But whatever the nominal structure there still remains the thorny question of perception, particularly among busy small businesses that do not have it in their make-up even to think of OH as an option.

Carrina Langelaan, policy adviser at the Federation of Small Businesses, argues that, while there has been no official research in this area, most small businesses would find it a real cultural shift to use an occupational health provider, however good the service.

“Speaking to our members, they say NHS Plus is a worthwhile principle; the premise behind it is a good one. But the problem simply is that awareness is minimal,” she explains.

“There is a perception that it’ll simply involve more cost and more paperwork. It is just not something they would consider as part of their business policy,” she adds.

In very small companies, too, the knee-jerk response when faced with having to tackle an occupational health or medical issue is simply to ring up the local GP rather than turn to an OH practitioner.

If the NHS is serious about shifting perceptions and getting the message through, rather than keeping on banging away at the doors of small businesses, it should consider changing tack, she suggests.

“You need perhaps to raise awareness among the people the businesses are going to contact – the GPs. If you can educate GPs to suggest to business that they go to NHS Plus, or that at least it is an option that is there, that may be a way forward,” she says.

But all this begs a question or two. If small and medium-sized businesses, by and large, are simply not ready for occupational health services or are far too suspicious and sceptical ever to take them up, is there a point in continuing?

Whether you have a local or regional structure, marketing campaigns and so on, if the horse does not want to drink the water, is it worth doing? Should NHS occupational health services not simply focus instead on getting their own back yards right first?

Certainly, despite the disillusionment with how it has turned out in practice, Perry, for one, is certain NHS Plus is something that should be persevered with. It may not be making money for the NHS, or doing what people originally thought it would be, but it is nevertheless meeting a need and making a difference to some businesses.

If part of the remit of any occupational health service is to spread the good word about employee health and well-being then NHS Plus, for all its faults, should continue, she suggests.

“Even those businesses that have not progressed with it have found the conversation helpful in terms of getting some advice about what they should be looking for,” she explains. “It has not been 100 per cent successful, but I would say it is useful.”

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