What will the next 20 years bring for occupational health?

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A report published in June on the role of OH over the next 20 years is already stimulating comment from individuals and organisations.

What will be the role of OH over the next 20 years as our workforce ages? To answer this you need to know the following: what the drivers and constraints on resources will be; who will be delivering them and from where and what disciplines; how changing technologies will transform provision; and how OH needs to respond to the launch of the proposed new health and work assessment and advisory service. The increasingly multidisciplinary landscape of the future might raise the question of whether or not OH should even continue to be called occupational health.

A new report from the Council for Work and Health, Planning the future: delivering a vision of occupational health and its workforce for the UK for the next five to 20 years, seeks to answer these questions.

The report, published in June 2013, has already sparked a major debate across the OH and medicine spectrum, says John Harrison, who wrote the report and is chairing the council working group.

“I have been very impressed by the enthusiasm with which various professions have been engaging with this project. It is bringing together what perhaps have been regarded as disparate groups – OH doctors and nurses, physiotherapists, psychologists, rehabilitation specialists and so on. There is a wide range of groups that are now engaging in this discussion,” he says.

Group engagement

It is very clearly a discussion and debate that needs to be had. In many respects, OH is at a pivotal moment. Its skills are resonating with the Government’s agenda of wanting to reduce the welfare bill by supporting more people back into paid employment, with OH practitioners expected to be at the heart of the new assessment and advisory service.

More widely, there is a growing recognition that the changing demographic of the UK workforce – notably the ageing of it, but also public health issues such as obesity and cancer – are both a challenge and an opportunity for the profession.

Yet we come back time and again to the question: can OH, a relatively small – sometimes even branded “Cinderella” – specialty deliver? Where will the practitioners come from to meet this demand, given that even the existing OH practitioner population is relatively mature and there are not enough younger trainees coming through the ranks?

As the report, in one of its more trenchant moments, highlighted: “Just at the time when occupational health is becoming so important to so many, the specialists within the OH team are under threat – fewer physician trainees are entering the profession and there are similar challenges for nurses and the allied professions.

“The funding for training is unsustainable, the research base is diminishing and affordable access to comprehensive OH services for the majority of the UK’s working age population is limited or non-existent.”

quotemarks[This project] is bringing together what perhaps have been regarded as disparate groups – OH doctors and nurses, physiotherapists, psychologists, rehabilitations specialists and so on.”

John Harrison, council working group

It was against this backdrop that the Council for Work and Health last year established a working group to examine six key aims and objectives, to:

  • define the UK populations to be addressed;
  • consider the drivers for and constraints of provision of OH resources;
  • conduct a review of the evolving UK health service and health education economies and the potential impact on the provision and development of OH resources;
  • map key stakeholders and the actions required to manage their expectations;
  • provide a prospectus to secure support and future funding for the project; and
  • formulate the communications strategy in support of the outcomes of this work.

The report was created through a combination of a literature review, telephone interviews, a stakeholder workshop – held in January – and the creation of a number of employee case studies.

As highlighted below, the result is a wide-ranging discussion around the notion of the working-age population, where the remit of OH should begin and end, the need for OH to become more of a mainstream specialty, the likely forces for change and the potential implications for the supply and demand of OH services.

Moreover, this is only the beginning of the process. As Harrison highlighted, there is now a lively, wide-ranging debate underway. Further to this, over the next two years, the council intends to study and openly debate around defining the role, skills and competencies of a future OH workforce and future service delivery models.

Keith Johnston, managing director of Syngentis, the not-for-profit health and work company spun out of NHS Plus that has supported the project, believes a key aspect will be a national marketing and communications strategy for OH to help the public (and employers) better understand what OH is, its value and how to access it: “If we can create a common language that we use to explain the benefits of occupational health and the future need for workers, individual businesses and the UK’s economy, then that will be enormously powerful and enable real change.”

National strategy

It will also examine the creation of a national marketing and communications strategy for OH to help the public and employers better understand what OH is, its value and how to access it. Another strand of work will be to study how inward-facing education and communications can be improved to ensure “a sufficient capacity of suitably trained and competent practitioners to deliver the demanded interventions”.

Council chair Diana Kloss agrees that, in terms of workforce at least, OH is in something of a “parlous” state at the moment. “There is going to be a huge shortage of numbers,” she warns. “There is a big opportunity now because of the Government adopting occupational health, admittedly with the motive of reducing the welfare bill, but the establishment of the health and work assessment and advisory service will need OH professionals, who are going to be in short supply.

“If the Government wants to do things like this it is going to have to support further training and competency for OH professionals, otherwise I do not know where we are going to get the people from.”

As a starting point for debate, the report is long overdue, especially in its recommendation that OH be recognised as a mainstream specialty, argues Christina Butterworth, deputy chair of the council and president of the Association of Occupational Health Nurse Practitioners.

“The next stage of this project is to ask what level of competence do we want and how do we promote OH as a profession? OH is still not very well recognised during general nurse medical training. We must help to market what OH does for the country and the significant impact that we know we have,” she says.

quotemarksIf the Government wants to do things like this it is going to have to support further training and competency.”

Diana Kloss, Council for Work and Health

“This is looking way into the distance and asking: who are the population going to be, what will their needs be, what competencies will be needed to meet those needs and who will we need and how?” says Dr Richard Heron, immediate past president of the Society of Occupational Medicine, who was in office while the report was being drafted and also sits on the council as the society’s representative.

“So it’s turning it on its head from simply saying ‘this is who we have now and what we should be doing’. The report is valuable in that context in that it is looking at things in a slightly different light.

“It is saying, first, there is an inexorable increase in the cost of health, especially in a country such as the UK with an ageing population, so the prevalence of non-communicable diseases is increasing and the ability to pay is challenging NHS budgets. Second, there is a difficulty in incentivising people to intervene in a preventative way to reduce the burden of that future cost.”

Healthy influence

Within this, the role of the workplace in terms of its ability to communicate and deliver health prevention and promotion remains largely untapped.

“If you can influence people’s health such that their overall health risks or outcomes are improved, that can make a substantive impact on cost profiles for the economy. And who are the experts at the interface of that? That is, of course, the OH workforce,” Heron says.

But OH will need to recognise that, given its own limitations on numbers, it is likely to be a varied and multidisciplinary workforce that delivers this provision. It could become more of a facilitator, overseer or commissioner of services within the workplace setting, with its own expertise then brought to bear on specific areas, such as, perhaps, health and safety or risk assessment, or at a more strategic level.

While the NHS will remain the “gatekeeper” for immediate or chronic care, for secondary care interventions and operations and for community-based primary care provision, there will be an increasing incentive for employers to step in other sections, forecasts Dr Steve Iley, medical director of health services at Axa PPP healthcare.

“OH is becoming broader. The traditional OH as just a physician, is that likely to be the case going forward? It is going to be a much more multidisciplinary approach,” he says.

But there may well need to be quite a significant change of mindset, not least in terms of how OH is viewed within the health community, argues Graham Johnson, clinical lead for nursing at Bupa Health and Wellbeing: “There will need to be an acceptance and acknowledgment that it is going to be a multiskilled speciality; I cannot see OH nurses doing everything, and nor should they.

“So we will need to be embracing OH technicians, specialist ergonomists and so on. It will be multifaceted provision and it will be delivered very differently to how it is now.”

Key findings

Context

The report recognised that the changing demographics of the UK population, particularly the working population, are bringing the interface between work and health to the centre of political debate.

Issues include the ageing of the working population, the rising demands and costs of healthcare, how economic growth can be stimulated and maintained and how people out of work and on benefits can be supported back into the workplace.

As the report stated: “Occupational health professionals have a pivotal role in advising employers and employees of ‘what good work looks like’, and creating the evidence base for defining what physical and mental capabilities are required to deliver it.”

Yet, just as OH is becoming increasingly important, the profession is facing something of a workforce crisis. To that end, the report recommended OH “should be a mainstream speciality that is integral to protecting, maintaining and improving the health of the working-age population”.


Extension of definition of “working-age population”

The report examined what the notion of “the working-age population” will mean over the next 20 years. It argued it will need to encompass those aged between 16 and 75 and in work, those with a higher risk of falling into worklessness, those with pre-existing conditions known to affect fitness to work, those with an increased prevalence of chronic disease (especially the over-50s) and those working in smaller businesses.

However, it emphasised it would be unrealistic “to extend a responsibility for advising about fitness for work to people that are unemployed”.


Forces for change

The report identified three key driving forces for change over the next 20 years: finance; demographics; and long-term and chronic conditions. But technology, education and training would be other important catalysts for change.

  • Finance: there will be huge financial pressures on government agencies, including the NHS, as the UK adapts to care for an ageing population, the report recognised, adding: “This presents opportunities for occupational health to position itself within mainstream healthcare. Work and the workplace can be used to promote health and wellbeing through healthy lifestyles, health risk management and supporting people with long-term conditions as part of integrated care pathways.”
  • Demographics: the report cited King’s Fund predictions that over the next 20 years the population in England will grow by eight million, to more than 61 million, with increased ethnic populations, more people living on their own, longer life expectancy for men and women, longer healthy life expectancy and more people aged between 65 and 84.
  • Chronic and long-term conditions: the report identified key challenges as including the health issues arising from obesity, the fact that fewer people are now dying from cancer – and therefore being able to carry on with their working lives – and the growing number of people who will be living with some form of dementia by 2021.
  • Technology: the report predicted that technological changes will have a great impact on the workplace, citing forecasts by the Californian Institute for the Future that “smart machines” will increasingly replace humans for certain tasks and augment our capabilities for others.

Developments in areas such as biotechnology and nanotechnology will create new processes and materials – and potential risks, it argued. There may also be challenges around how data is collected and used, while social and multimedia technologies will transform how people interact and communicate.

“Telemedicine and telehealth will come to the fore, again with opportunities for occupational health. The new technology will enable true global marketplaces to become the norm, reinforcing the need for 24/7 operations,” the report stated.

“UK OH will need to assume an international perspective if it is to remain relevant. New skills founded on ways of thinking, communicating and inter-relating with technology will be essential.

  • Education and training: changes in the education and training of healthcare practitioners will pose another challenge. The creation of Health Education England and Local Education and Training Boards “will stimulate change in the current models of training in England”, the report argued.

Alongside this, there is an ongoing review of the training of doctors – the General Medical Council’s (GMC) The Shape of Training – and the GMC has proposed the establishment of a national school of occupational medicine in England.

While there are also reforms going on within programmes for allied professions, the report made clear that “there is a critical need for more postgraduate courses and students, creating an opportunity to integrate this into multidisciplinary occupational health training”.


Implications for demand and supply of OH

The report emphasised that “carrying on as normal will not be an option”. OH was being offered a significant opportunity, “but may have to decide the level at which it incorporates preventative wellbeing strategies into its arsenal”.

The trend towards care being increasingly moved into the community could mean some OH services would have to follow. There will be a need for OH to become increasingly “effective in engaging with local health and wellbeing boards and clinical commissioning groups”.

There is likely to be a continuing need to engage independent providers, employee representatives and employers, particularly those with in-house OH services. Alongside this, there will need to be an emphasis on reviewing the knowledge and skills required of the multidisciplinary workforce as well as the implications of seven-day working for GPs and hospitals and potential demand from employers for 24/7 support.

OH will need to “position itself as a major player to tackle obesity”, be ready to support people with or recovering from cancer in the workplace and people working from home or wishing to use telemedicine technologies, it added.

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