Solutions to the decline of OH doctors in the NHS

Urgent action is needed in response to the decline in the number of NHS doctors who are accredited specialists in occupational medicine. A recent meeting of OH practitioners debated solutions to this problem and considered whether OH nurses could take on work previously done by doctors. Dr Siân Williams and Deborah Mathews explain more.

A crisis is looming – the number of doctors choosing to train in occupational medicine is in decline. In 2011, the Faculty of Occupational Medicine (FOM) estimated that to meet the demand for accredited specialists (or consultants), it needed to recruit 37 new specialist trainees each year. However, the annual intake has only been 15. Anecdotal evidence suggests that recruitment of consultants into occupational medicine is already a major problem, particularly for the NHS in London.

To address this supply/demand gap, a multidisciplinary group of NHS OH professionals from the London area met for a one-day workshop in August 2014. The aims of the day were to:

identify national legislation and guidance requiring involvement of a consultant in occupational medicine within the NHS OH service;
articulate what these consultants currently bring to the service;
discuss the added value that a consultant in occupational medicine brings from the perspective of the organisation, the team and the client;
pinpoint the qualities and skills that OH advisers (OHAs) would need to independently manage cases to conclusion; and
suggest practical solutions.

The workshop was attended by three OH service managers, two lead OH advisers, three OH doctors, a physiotherapist, a nurse manual handling adviser, an employee relations officer and a project manager from the NHS Health and Work Development Unit. Two participants were also from the national school of occupational health, including their lead, Professor John Harrison.

The workshop allowed an open and frank debate between the different disciplines represented. The attendees brought with them their experience of various OH service models. There was a general consensus regarding the points detailed below, however, the group was small and it acknowledges that there will be differing views among the wider OH community. It is hoped that the comments below will contribute to further discussions and practical solutions to the challenges faced by the current workforce.

Some of the areas identified are directly related to healthcare, while others are more relevant for NHS OH services that undertake external work, or those providing services to other employment sectors. The group recognised that this may not be a comprehensive list.

Occupational health service accreditation

The Department of Health (DH) has mandated that all NHS OH services must acquire accreditation through the FOM’s scheme, Safe Effective Quality Occupational Health Services (SEQOHS, 2010). Accreditation standard C2.3 states that “an OH service must have access to an accredited specialist in occupational medicine”.

Training of junior doctors in occupational medicine

The 2011 DH document “Healthy staff, better care for patients – realignment of occupational health services to the NHS in England” states that: “Occupational health services need to have the resource to train both doctors and nurses to specialist level.” A consultant in occupational medicine will be required to supervise medical trainees.

Infection prevention and control

Access to a consultant in occupational medicine is required for:

new healthcare workers undergoing pre-employment checks for tuberculosis and blood-borne viruses (DH, 2007);
healthcare workers who are exposed to blood-borne viruses through occupational exposures; and
healthcare workers infected with a blood-borne virus (HIV, hepatitis B, hepatitis C) (Public Health England, 2014; DH, 2007; DH, 2002).

Ill-health retirement

Ill-health retirement applications under the NHS pension scheme state that the medical section is “to be completed by the occupational health doctor”. However, it does not stipulate by a consultant in occupational medicine, and also states: “Where this is not possible, a GP or specialist can provide a medical report.” (NHS Form AW33E).

Other pension schemes vary in their requirements for involvement of a consultant in occupational medicine. NHS OH services will need access to a consultant in occupational medicine when tendering for contracts, which do require involvement of an accredited specialist.

HSE-appointed doctors

The Health and Safety Executive (HSE) appoints doctors to undertake statutory medical surveillance under the Control of Substances Hazardous to Health Regulations, eg ionising radiation, diving, lead and asbestos. The HSE states that these doctors must have the “minimum diploma in occupational medicine”; but there is no requirement to be an accredited specialist.

General Medical Council

There is no requirement from the General Medical Council for OH doctors to be involved where a doctor is unwell or has an infectious disease. The GMC advises: “If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgment or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients.”

What do OH consultants bring to an NHS OH service?

Workshop members presented clinical cases where the input of a consultant in occupational medicine was deemed necessary and the following themes emerged:

a perception that more senior clients (ie senior managers or senior clinicians) needed to be seen by a consultant/physician;
a lack of confidence by some OHAs to conclude a complex case where the outcome may have a significant impact (eg redeployment, dismissal, litigation);
the presence of some organisational cultures (within the NHS) that expect complex cases to be seen by a consultant, and that doctors will be seen by other doctors;
new diagnosis/confirmation of diagnosis/assessment of treatment pathways was seen as appropriate for assessment by an occupational health physician (although not exclusively as other medical specialties such as occupational psychiatry may also be appropriate);
doctors may be required for complex cases involving medical staff (especially senior medical staff) due to the occupational physician’s working knowledge of medical training/supervision/work demands;
doctors may be also required for complex clinical cases eg major psychiatric illnesses; and
doctors have more influence within the organisation with managers more likely to implement recommendations from a doctor/consultant than an OH adviser; and some clients perceive that a doctor’s opinion will be more influential.

Added value of a consultant in occupational medicine

The group then considered the added value that a consultant in occupational medicine brings, taking into account the perspective of different stakeholders. There were some areas that were considered specific to the consultant role and other areas where the consultant could make a significant contribution to the senior management team. Consultant-specific roles require:

an increased level of clinical governance and expertise;
supervision of medical trainees; leading research and contributing to the evidence base;
enabling trusts to bid for external contracts that require OH consultant input;
challenging specialist reports and GP fit note advice, for example making expert
decisions about a patient’s fitness to work, despite advice to the contrary from non-OH specialists;
developing and representing the clinical specialty of occupational medicine; and enabling implementation of national guidance, ie for HIV-infected healthcare workers.

Consultant contribution/partnership roles require:

policy development;
strategic development;
training and teaching – the OH team, managers, HR and undergraduate and postgraduate medical and nursing students;
engagement with the trust at a senior level, eg trust board and consultant meetings;
working at a national and regional level; and
an element of research, clinical audit and service evaluation.

Skills for OH advisers to manage cases independently

The group acknowledged that rather than “firefighting” these issues, a different model of OH delivery is needed, at least in the short term. With fewer consultants working in occupational medicine, the group looked at what qualities and skills could support OH advisers to manage complex cases through to their conclusions independently. While the group acknowledged that some OH advisers are already well equipped, there are gaps in education and clinical support that would ensure consistent high-quality practice. The group identified the following attributes that are needed for successful complex case management:

knowledge of basic employment law, legislation, guidance and policy;
history taking skills;
report-writing skills, including clear rationales for recommendations and adjustments;
confidence in self and instilling confidence in others;
clinical knowledge and access to up-to-date and appropriate clinical resources, eg specialists, appropriate websites, evidence-based guidelines, ethical guidance;
use of the biopsychosocial model;
ability to integrate health/legal/social complexities;
“being an expert” – being confident in decisions made;
leadership and “chairing” skills, eg ability to lead and chair case conferences, manage differing views and opinions and summarise discussions clearly;
ability to review, interpret and incorporate evidence and guidance into policies and practice (including reports and advice to managers);
coaching skills and techniques such as motivational interviewing; and
knowledge of, and confidence in giving, positive health messages.

Practical solutions

Finally, the group considered possible mechanisms for enhancing the training of OH advisers, and accessing other specialists, so that complex cases could be managed through to conclusion without, or with less frequent, involvement of a consultant in occupational medicine.

To enhance the skills of OH advisers and other non-medical OH professionals, the group considered a liaison between Health Education England and relevant experts to develop training packages and updates. Suggestions included e-learning packages (leading to continuing professional development accreditation or advance practice status) and workshops. Although likely to be a longer-term aim, the skills and competencies identified in this workshop could be built on and be included in the core training for specialist OH nurses in future.

Many medical specialties have developed clear clinical and management pathways. It was agreed that similar pathways could be developed for OH, with strict referral criteria from OH advisers to other clinical specialists. Pathways would depend on the presenting problem and might include referral to specialists in occupational medicine, OH psychiatry, psychology, physiotherapy or respiratory medicine. Regardless of whether clinical pathways are developed, these and other specialists (for example, GPs, infection-control specialists, public health professionals and strategic health and wellbeing leads) could contribute to the wider multidisciplinary OH team.

An alternative to bringing other specialists into every OH team could be either fast-tracking to other secondary care services (which the group acknowledged may be controversial), or shared specialist services eg consultants in occupational medicine, physiotherapists, psychiatrists and ergonomists working from a specialist “complex case” centre. This pooling of resources from several trusts could provide high-quality specialists for the management of complex cases.

Conclusion

The workshop highlighted the breadth of skills needed by OH professionals and the added value that a consultant in occupational medicine can bring to the multi-disciplinary team and to an organisation. There is a declining number of trainees in occupational medicine, and even if this reduction is reversed by the national school of occupational health, there will continue to be a shortage of consultants in occupational medicine in the short term. Some of this gap can be filled with enhanced training of OH advisers, and accessing the expertise of other clinical specialities.

Several groups are considering the future of occupational health and we hope that the ideas above concur with their conclusions and add some options. Whatever the outcome, urgent action is needed to address the OH staffing difficulties faced by some NHS trusts.