Many were surprised when members of the Society of Occupational Medicine (SOM) and the Faculty of Occupational Medicine (FOM) voted in September 2014 to reject the proposal by their respective boards to come together as a single OH body. More widely, it has thrown open the debate on how the different arms of the profession can, and should, work more closely together in future. Nic Paton examines the ramifications for OH doctors and nurses.
The society opened its doors to associated healthcare professionals working in OH in 2012, so many saw a combining of the two organisations as a logical progression. The vote against the merger is also a significant setback for the leadership of both organisations, and for those who wanted to see the different strands of the profession working more closely together. So, what happened? And what happens now?
Single occupational health body “no” vote
The first thing to be aware of as Dr Alasdair Emslie, president of the SOM, makes clear, is that the vote was a close-run thing and was very nearly carried.
Speaking exclusively to Occupational Health, he says: “In terms of the overall message, more people voted for than against it. The faculty voted in favour of it and just under 61% of the society. But it required a two-thirds, 67%, positive vote. Being just 6% short of being able to do that was disappointing.”
In particular, there was vocal opposition to the proposal from physicians in North-West England. And, as Emslie fully accepts, it will now be important for all sides to reflect on why this might have been, and respond accordingly.
“The majority of people wanted a single organisation, and so we need to take that forward. But we also need to consider those who were vehemently anti [the proposal] and understand why that was and what it is they are wanting,” he concedes.
“The single organisation would not have been a panacea but it would have been an obvious home. The most important thing now is we continue to be a welcoming home to nurses, and we will work to develop a programme that supports nurses in terms of their revalidation needs.
“Occupational health in 2014 is a multi-disciplinary affair; the closer we can mirror what is happening in the workplace, the better. We also need to continue to reach out more to OH advisers and allied health practitioners to create a broader base and home,” Emslie adds.
Reaction to the “no” vote
In the wake of the announcement of the result of the vote, both organisations made it very clear that this setback would not impede the ever-closer working relationship between the two bodies and non-physician elements of the profession.
In a joint statement published after the vote, they emphasised that they would “continue to work closely together to represent the interests of health and the workplace and the occupational health community”.
This would include the society placing “a greater emphasis on extending its membership and attracting more nurses and AHPs [allied health professionals] to become members”.
To that end, the SOM pledged to “undertake a review of the services that it provides, including considering extending its quality assured appraisal scheme so that it meets the needs of these groups. It will continue to provide excellent education and continuing professional development for all of its members”.
The society also stressed it would now be “liaising with occupational health nurses to find out how it can better support them in the future”.
There would, it said, be “a shift of focus where it actively considers encouraging more nurses to join and developing new services specifically for them”.
The FOM and SOM would, between them, “support nurses in the development of training and enhancing OH nurse competencies as part of its work with the new National School of Occupational Health”.
Nevertheless, the idea of a combined single organisation does now appear to be off the agenda in the short and probably medium term.
Emslie, for one, concedes: “I do not think there will be another vote during my tenure; I think it has probably been knocked into touch for a period of time.”
But he adds: “A huge amount of effort was put into it and there is a commonality between what we do and what the faculty does. So we need to use this vote as a way to work more closely together to try to create a single voice for occupational medicine. I am not sure yet what that will look like, and we will of course need to consult on it.
“Where there are obvious synergies, such as around our back office operations, we should look at those. For example, do we really need to run two separate IT systems and two separate properties? We should be exploring things like this and looking at how we can save costs by working more closely together.”
FOM president Dr Richard Heron is more optimistic, however, that the idea of a single organisation is not dead in the water. “Since the vote I have had multiple letters expressing surprise at the outcome and support for the process. So I, for one, am less pessimistic about being able to continue in this direction,” he says.
“I was disappointed some who came out against did not choose to engage with the debate earlier, as many of the options they proposed as alternatives had already been looked at and found to be unviable,” he adds.
“I would encourage those who want to influence change to put themselves forward for board positions on the SOM and FOM, and actively shape the future from within.
“Let’s not forget, there was a very high turnout and an overall majority, and the faculty did vote in favour. So, constitutionally, the view of faculty members to progress the idea must be considered by the board. For me, the direction of travel they seek is pretty clear – a common desire for a single voice to strengthen the multidisciplinary field of occupational health and, at the same time, to recognise and assure the quality of the unique disciplines, such as occupational medicine, occupational health nursing and physiotherapy.
“I think we have to look very carefully at what this means, how we can deliver this vision and assuage the concerns of those who were doubtful,” says Heron.
Should OH nurses go it alone?
What, then, was the reaction of OH nurses to the vote and, more widely, where does this leave them in terms of their voice and representation within the profession?
The consensus among OH nurses appears by and large to be one of disappointment that the vote was not carried, that it was a lost opportunity for all sides of the profession.
“I am disappointed it didn’t go ahead. I understand there were some people who had hesitations, not so much about the fact it would have meant more nurses joining, as the way it was being progressed. People felt it was too rushed,” says Diane Romano-Woodward, president-elect of the Association of Occupational Health Nurse Practitioners UK (AOHNP).
“I am optimistic that it may still happen, but I think it may be a few years away now. I do not think it is even going to be during my time as AOHNP president. I think there will need to be some time to rethink things,” she concedes.
“Just because two lots of physicians have decided not to merge does not mean our own course should falter. I do not think it will put us off our stride of promoting OHNs and nurse practitioners,” she adds.
Indeed, the role of the association, and that of the Council for Work and Health, in promoting the OH agenda, and representing OH nurses within that, could well become more important in the future as a result.
As Graham Johnson, lead nurse at Bupa Health Clinics, puts it: “There needs to be some reflection for the nursing community, now that we are not going to be able to join with our physician colleagues. We will need to be rethinking what will be the most appropriate body for us.
“OH is not now a serious agenda for the Royal College of Nursing, at least not through its Public Health Forum. So there may be an opportunity now to look at alternatives. There is an opportunity for nurses to raise our profile,” he adds.
Janet Patterson, OH adviser and group OH coordinator at bakers Greggs, agrees there was surprise at the vote result. “I thought it was going to be a majority vote and go ahead – so I am slightly deflated,” she says.
She adds: “In a way I think this could be an opportunity to develop a bigger voice for OH nurses. OH has evolved over a number of years and now nurses are not sat behind doctors nearly as much as they once were. In many respects I believe the role of the OH doctor is eroding, whereas the role of the OH nurse is becoming stronger.
“Nurses now do a lot of things that doctors used to do in healthcare in general, not just in OH.
“Twenty years ago you would not have dreamt of a nurse doing a sickness absence assessment; now most nurses lead on them. So, possibly some doctors felt threatened.
“For me, I see this as an opportunity for SOM and FOM really to try and push things, to sound out what they can offer to nurses. So I do not see this as the end of it. And I do think the idea of a single organisation will raise its head again at some point,” she argues.
Karen Coomer, director of OH provider KC Business Health, says: “It is disappointing, but it was positive that 60% of doctors voted, so, in that context at least, it was not a washout. I think the best option will still be greater collaboration between doctors and nurses and more working in partnership so we can pool resources.
“There is, obviously, some discussion to be had about the concerns [those against the plan] had. It would be useful for us as nurses to better understand what their concerns were, and how we might be able to contribute or help to allay them.
“I think it is sad because it was a really good opportunity. There are some OH physicians out there who are really proving the advantages of working as part of a multi-disciplinary team,” she adds.
Anne Harriss, reader in educational development and occupational health course director at London South Bank University, agrees: “People like Olivia Carlton [immediate past president of the FOM] have also been exceedingly supportive of OH nurses.
“It is clear there were some disgruntled doctors, and the letter from the North-West that went around was probably the death knell. Some doctors may have felt threatened by the excellence of OHNs.
“But the next discussion from here needs to be about developing our own voice,” she adds.
Doctors’ key objections
Ahead of the vote in August, a group of 16 occupational physicians practising in the North-West of England circulated a letter to all SOM members highlighting a range of concerns about the proposed move to create a single organisation.
This move, it became clear in the wake of the vote being lost, proved to be a crucial moment of the campaign. As such, looking in detail at what is said, provides the clearest insight into the thinking, and fears, of those who opposed the vote.
The letter first argued there were concerns that the two boards were “failing to provide explicit detailed answers on what they propose for our medical specialty, and are not adequately considering the options”.
The physicians agreed that there was currently “a crisis of recruitment into the specialty of occupational medicine and a lack of clarity of our message to government and employers”.
This, it added, had been “a significant and growing problem for a number of years”.
But the move to create a single organisation would result in a “joint organisation with a number of other disciplines, and ‘other potential members’ from as yet unspecified disciplines – if any”, they said.
“These would not necessarily share our professional skills and therefore may not have the interests of the specialty of occupational medicine as a priority,” they added.
Furthermore, the FOM and SOM boards, they argued, were “failing to allow consideration and discussion of a number of other options for increasing recruitment and improving the clarity of our message to government and employers”.
The two boards also had “no plan B or plan C at present”.
The letter then set out six key concerns or objections to the plans as they had been communicated to members. These were:
- The plan included merging into an organisation “with nurses, physiotherapists and ‘other potential members’ who vastly outnumber doctors and would have their own agendas and standards”.
- The eventual detailed structure of the new single organisation was, they felt, still unclear, “and as a result we are being asked to vote for something with a range of unknown possible outcomes”.
- No second vote was on offer. “Once the structure of the new single organisation is negotiated with other vested interests, we will then have voted to join the unknown entity that emerges, irrespective of its nature, composition and governance structure.”
- There was no guarantee specialists in occupational medicine would lead the new organisation. “Indeed there is no guarantee that the president/lead of the new structure will be medically qualified at all.”
- It was “entirely possible” that any non-medical majority group within the single organisation could run the executive committee and “be hierarchically superior to the vestige of the Faculty of Occupational Medicine subsumed within the single organisation”.
- The head of the single organisation would not be able to both represent medical specialists as well as non-medical competitors, “and will have difficulty representing the interests of one member faculty if this is in conflict with the views or interests of another member faculty, much less of a wider membership not necessarily qualifying to be part of any professional faculty”.
The 16 physicians then went on to propose four alternatives to the idea of a single organisation. These were:
- that the faculty should become an intercollegiate faculty within the Royal College of General Practitioners and the Royal College of Physicians;
- that the two organisations should look at the Royal College of Physicians of Ireland’s Faculty of Occupational Medicine to learn how it has gone about attracting and admitting international members;
- that the medical memberships of FOM and SOM be merged, “without any other professional disciplines, reducing duplication of effort, bureaucracy and cost”; and
- that increased lobbying of government and employers should take place “to improve the attractiveness of our training environments”.
The 16 then concluded: “None of these options involve the high risk of voting to join an unknown organisation or becoming a minority voice in an organisation shared with other non-medical disciplines.”