Reading the runes for the future direction of occupational health

The future direction of occupational health was a central talking point – and the subject of a keynote panel discussion – at November’s Royal College of Nursing and Society of Occupational Medicine occupational health nursing conference. Nic Paton listened in.

This year could turn out to be important for occupational health. The government’s expert working group review into the evidence around occupational health, including new funding models and “where responsibility for OH support should fall”, is due to report this year.

As part of this process, and set out in the government’s Prevention is Better than Cure public health “vision” announced in November, we should this year also see a public consultation being carried out to find out how access to occupational health can be improved and how employers can do more to support workplace health.

The panel members

Nick Pahl, chief executive of the Society of Occupational Medicine
Christina Butterworth, chair of the Faculty of Occupational Health Nursing
Dr Rob Hampton, GP and occupational physician, and Public Health England Medical Champion for Health and Work

This all meant it was timely that November’s Royal College of Nursing and Society of Occupational Medicine (SOM) occupational health nursing conference featured panel discussions on both “future developments in occupational health nursing and practice” and “the future direction of occupational health”.

As more of a slow-burn issue, we’ll be looking at some of the discussions that came out around the future of occupational health nursing and practice within Occupational Health & Wellbeing and on this site in the coming months.

But the “future direction of occupational health” panel discussion featured SOM chief executive Nick Pahl; Christina Butterworth, chair of the Faculty of Occupational Health Nursing; and GP and occupational physician Dr Rob Hampton, a Public Health England Medical Champion for Health and Work (among other titles) and clinical lead on one of the Fit for Work pilots between 2008 and 2012.

Nick Pahl opened the proceedings by agreeing there did appear to be a real opportunity for occupational health at this time. “In terms of the future direction of occupational health, there is an opportunity because I think we know about half the working population don’t have access to occupational health. And there is a particular opportunity for nurses, as nurses of course often lead occupational health services,” he said.

“It is not that easy, because a lot of that 50% of unmet need is from SMEs, so how do we get access to that group who find it hard to access occupational health? I think one of the things that the government is thinking about is how you create platforms or make things work regionally to link up occupational health providers with SMEs.

“Clearly, when you expand occupational health, you also need more people to deliver that service, and occupational health nursing will be a core part of that. There is also an opportunity to use technology more, although we need to be aware of the inter-personal communication you need in some of these spaces and so technology can only go so far.

“There are also all the other health professionals – doctors, psychologists, physiotherapists, technicians and so on. One of the things SOM wants to do is to try and bring together all these health professions, perhaps in a summit next year, looking at what their competences are of those different groups; what is the added value and how can we work together better in a multi-disciplinary team? Because I think one of the things that occupational health can do better on is teamworking.

“My final point is that the government is behind this occupational health agenda. I do think the government really wants to kickstart this, whether through funding, incentives or reform of the tax system. So, I think the future is bright, if we can meet that demand with the right workforce, and I think nurses are absolutely core to that,” Pahl added.

Positive time for health and work

“To reflect on what Nick said, I’ve been involved in this at a strategic level for around eight years and I have never been more positive that, if the government’s Improving Lives: the future of work, health and disability aspirations are met and followed through, then this is going to be a positive thing for health and work generally,” agreed Dr Hampton.

“But one thing I’ve always struggled to find the logic of is that people in employment by and large have really good access to OH expertise from clinicians, with professional standards and good training. Yet, once somebody is out of work or needing employment assistance, while there are a whole host of different employment advisers out there working for all sorts of different employment organisations, they are without the same standards or with very little clinical input,” he argued.

To that end it was imperative that OH expertise was somehow more evenly distributed wherever anyone was employed or unemployed, he suggested. “I’m a great believer that regional networks are a big and important next step. So that, you know, a couple of GPs with an interest in Leicestershire will know who the OHA is, the employment adviser, the consultant occupational physician and occupational psychologist and so on. At the moment they’re all separated. If we’re going to really have a cohesive workforce across there we need to be building those networks soon, and I am reasonably confident that will be so.”

“I’ve been in occupational health a while; I started off in an occupational health service that had a treatment service – I loved it!” said Christina Butterworth. “But it really is changing – our role – from that individual clinical care, for organisations as well as for individuals. Are we ready to step back from that holding of the hands of the individuals to really start to advise organisations on what ‘good’ occupational health looks like? So, give them the technical advice we’ve all been trained to give; give it confidently; make sure they have the right people doing the right jobs at the right time; and also us working as part of that wider clinical team,” she argued.

Need for better OH mental health training?

At this point questions were put out to the audience, with the first one on whether the panellists felt occupational health nurses needed to offered better, or more extensive, training in supporting and managing mental ill health?

“Occupational health is so diverse that trying to get every element into a course is very difficult,” said Butterworth. “I think mental health, a bit like we do with learning our spirometry or audiometry, is an additional skill that we need to have training on.

“We’re seeing mental health is coming up more in the agenda, and therefore I would encourage all of you to look at different courses in order to understand mental health and mental wellbeing. However, my biggest issue and concern at the moment is that everyone is being labelled as ‘mentally ill’, when they are just sad or low, or just worried about life events. Let’s stop stigmatising people by labelling them as mentally ‘ill’ when it is a natural part of being a human being,” she added.

“We also need to understand the mental health of nurses and occupational health nurses; the ‘care givers’ who perhaps don’t care for themselves,” emphasised Pahl, citing SOM’s recent research into “burnout” and work-related stress among medical practitioners.

Extension of fit notes to allied health professionals

The questioning then turned to fit notes and, in particular, the government’s stated aim that allied health professionals as well as GPs should be allowed to sign fit notes. The questioner referred back to Dr Hampton’s presentation earlier in the day in which he had highlighted that signing fit notes was, for him as a GP, one of his biggest causes of anxiety and emotional stress.

“The idea of other health professionals issuing fit notes brings me out in a rash,” said the questioner, to laughter. “If that role does move to others, then that feels like it might simply be shifting the anxiety to that group of people, presumably. And so what provision would there be to support people if that came about?” she asked.

“I have yet to meet an OHA who says, ‘GPs are doing a job at fantastic job at this, well done’,” conceded Dr Hampton. “So I think there is an issue here and it has been recognised again and again that a GP can really scupper a well thought-out rehabilitation plan just by an ill thought out note. So it is a system that needs reforming.”

“From the allied health professionals, there is a movement, a really strong movement, for them to get involved in this, to be signing fit notes. The professions want to get more involved with that. Partly I guess because some of the work they are trying to do is the way the GPs behave around fit notes and how that can be a barrier to some of the work they are doing, so they have devised their own note. We will be trialling it in two or three areas of the country in the next few months to see how that works,” he explained.

“Speaking with OHAs here and just during the course of my work generally, I think there is a real 50/50 split between those who feel that, actually, yes they want to embrace this, and others who think ‘no way’ because of all the issues. I can see why occupational physicians, for example, may be dead against the idea of signing fit notes, because they feel that would remove their impartiality in case assessment.

“For me, the qualifying criteria here is that it has to be somebody who somehow who has become part of that primary care team or who can feed in to the inpatient/primary care team. People with OHA experience in that context may be ideally suited to do fit note certification – if they so want to. People who are OHAs working with employers probably would not be in the same position to do that.

“So I guess it could be an option for some people, and maybe a movement towards having OHAs within the NHS. For those who make that choice, it might be ideally suited. But for those who do not make that choice, it should never be mandatory,” he emphasised.

At this point, Helen Donovan, professional lead for public health, professional practice (nursing) at the RCN, highlighted the potential role that primary care nurses could play in this evolution, but also the anxieties many equally felt.

Butterworth also made the point that OH practitioners needed “to be careful what you wish for”. As she said: “As soon as it is out there as an option, how soon is your line manager, your HR director going to come and say to you, ‘wouldn’t it make my life easier if you did all of that work for me rather than the GP?’. Do you really want that? At the same time, we’re capable of doing it, but do we really want to do it? But of course at the moment we’re not being considered for it; it is people such as occupational therapists and rehab specialists who it is being proposed to, and that is totally appropriate for them to do that.”

Replacement model for Fit for Work?

The final question for the panel was what implications they felt the closure of the Fit for Work scheme to referrals last year had had for occupational health? More widely, in the current febrile political atmosphere, did the panel feel the aspirations outlined in Improving Lives were likely to be honoured politically in future?

“This is something the occupational health expert group has discussed: how future-proof is it from political changes?” conceded Nick Pahl. “The civil servants, obviously, they don’t know what their political masters will say in the future. But all they said that the case they felt they had made, the business case, was there, of the benefits to UK plc.

“Even in the event of a Labour government, or any other political party, it would be irrational to throw it out, because there is a case to be made that, if productivity is poor, this is one of the solutions. Also, there is the whole ageing workforce: I cannot see how they can’t look at health conditions and how they’re going to support people in work. So, you would think there would be rationale from our political masters for this though of course we are living in strange days politically,” he added.

For all the criticism of it, the Fit for Work scheme was based on the biopsychosocial model and had good return to work plans, pointed out Christina Butterworth. “The actual underpinning knowledge was great. Unfortunately, it just wasn’t implemented as well as we would have liked. The uptake was very slow.

“I still feel that there is a gap where people don’t have access or choose not to have access to occupational health; you still need that ability to ensure people are fit for work, and so something needs to come out as part of this paper that government is looking at as to what to do instead,” she said.

Dr Hampton highlighted his role as having been closely involved in one of the Fit for Work pilots. “If I can put in one phrase why that scheme was destined to fail, it was because there was no localisation. The referral system for GPs was by filling out a form on the internet, which was a bit dodgy, whereas now we all have our referrals integrated into our clinical systems.

“There was no locality commissioning part of it. One of the things the occupational health expert working group is trying to address is how to reach that same group of people, those who don’t have access to occupational health services? Whatever the solution might be, there has to be a local commissioning element to it so that it fits the natural wealth economy. So that would be my one driving theme to it,” he pointed out.

“Don’t look for a single provider; look for a group of independent occupational health advisers. But that is difficult to audit and manage, and therefore that didn’t go ahead. I still think that’s the best model,” added Butterworth.

Nick Pahl concluded the discussion by highlighting how at a recent industry forum SOM had held with some of the big occupational health providers, it had been clear that, for many firms working on this sort of scale, the economics of providing services to small and medium-sized companies often were difficult to make viable.

“But when we did a wider survey of the occupational health industry – about 100 organisations – it was small OH providers who felt there was the best opportunity here. They do want to pick up some of the slack, or the demand, that Fit for Work has left. So I would encourage you as potential entrepreneurs, or perhaps you are running your own occupational health consultancy, that there is an opportunity for a nimble, small OH company to offer services in the space that Fit for Work has left,” he added.

References

Prevention is better than cure: our vision to help you live well for longer, Department of Health and Social Care, 05 November 2018, available online at https://www.gov.uk/government/publications/prevention-is-better-than-cure-our-vision-to-help-you-live-well-for-longer

Improving lives: the future of work, health and disability, Department for Work and Pensions and Department of Health and Social Care, November 2017, available online at https://www.gov.uk/government/publications/improving-lives-the-future-of-work-health-and-disability

Key Issues in Occupational Health, RCN and SOM Occupational Health Nursing Conference and Exhibition 2018, https://www.rcn.org.uk/news-and-events/events/occupational-health

New report reveals UK doctors at greater risk of work-related stress, burnout and depression and anxiety than the general population, Society of Occupational Medicine, October 2018, https://www.som.org.uk/new-report-reveals-uk-doctors-greater-risk-work-related-stress-burnout-and-depression-and-anxiety

‘Fit for Work service scrapped in workplace health policy overhaul’, January 2018, https://www.personneltoday.com/hr/fit-work-service-scrapped-workplace-health-policy-overhaul/

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