Healthy Staff: Better Care for Patients. A Future NHS Occupational Health Workforce. A Report of a Workshop held at. The Work Foundation

Transcription

1 Healthy Staff: Better Care for Patients A Future NHS Occupational Health Workforce A Report of a Workshop held at The Work Foundation Thursday 8 th March

2 Contents EXECUTIVE SUMMARY... 3 INTRODUCTION... 5 BACKGROUND... 5 SUMMARY OF POINTS MADE BY DELEGATES AT THE WORKSHOP... 6 NEXT STEPS CONCLUSION ANNEX ANNEX ANNEX Introduction Are specialist OH physicians and nurses needed? Recruiting new trainees OH workforce in different countries OH and changing demographics References Appendix A

3 EXECUTIVE SUMMARY This workshop to discuss the workforce challenges for occupational health addressed three questions: 1. What three things should be done to make education and training and career structures in OH more fit for purpose and to re invigorate the academic base? 2. How do we ensure a closer match between workforce skills supply and future delivery models in OH? 3. How can the OH profession be encouraged to speak with a common voice and exercise leadership on behalf of the profession? Key points arising from the discussion were around real concerns that occupational health has not changed sufficiently to meet changed expectations. There is a need to redefine the role of occupational health within the health and wellbeing agenda and to determine the relative contributions to be made by occupational physicians, occupational health nurses and other members of an increasingly diverse occupational health team. This fundamental reappraisal will inform manpower planning, which should be needs based. It will also inform training requirements. There is a need to define the ideal occupational health team. Occupational health services covering a population of 40,000 to 50,000 staff would seem to be of sufficient size to offer the scope for specialisation and the provision of suitable training environments for doctors and nurses. It would also offer possibilities to participate in research and audit to underpin evidence based practice and contribute to the strengthening of the currently weak academic base. Future population centric workforce planning for NHS occupational health should take account of the needs of the NHS, as an employer, and the needs of the NHS to improve England s public health. Population health needs and new models of delivery of occupational health will be important considerations in estimating numbers of staff, effective skill mix and requisite competencies. The need for a common voice for occupational health was deliberated upon and no single solution was proposed. One option put forward was the Council for Work and Health. An alternative proposal was the coming together of the Faculty and Society of Occupational Medicine in the form of a new Royal College of Occupational Health. What is clear is that there is a compelling need for a body that will exert strong leadership to deliver the envisaged changes in occupational health and to communicate effectively with other key stakeholders, including the public, to raise awareness about the contributions that can be made to improved organisational performance and service quality. There is a need to engage with Health Education England regarding funding for academic and training posts. A reallocation of public funds, coupled with an employers levy, would assist the creation of rotational training posts involving the public and private sectors to widen training experiences. There should be a core curriculum for any practitioner working in occupational health. 3

4 The Council for Health and Work should lead the formation of a coalition of academic occupational health practitioners and academics with an interest in workplace or work related research to produce a strategy for the growth of academic occupational health. There is an urgent need to address recruitment and retention concerns in occupational health. The solution is multifactorial and includes improving training in occupational health during basic clinical training, positioning occupational health under the public health umbrella, effective marketing of occupational health, defining the career pathways for occupational health practitioners and improving academic opportunities as well as the academic profile of the specialty. New models of delivering occupational health should be explored to ensure access to occupational health for the entire working age population. Central to this will be developing the commissioning of occupational health. The NHS Commissioning Board will have an important role in the future commissioning of realigned regional NHS occupational health services. Health and Wellbeing boards will commission on behalf of communities and will need occupational health expertise and guidance. Clinical commissioning clusters may have a role to play in commissioning local non specialist occupational health services. 4

5 INTRODUCTION NHS Plus coordinated a workshop in March 2012 to discuss the workforce challenges for occupational health. This was attended by a wide range of delegates (See annex 1) This report sets out the views of delegates at that workshop, which were formed around a number of themes: medium and long term workforce considerations for OH The points and issues raised will support education and training commissioning, workforce planning and numbers planning. positioning of occupational health to support the health and wellbeing agenda A number of points were raised in relation to occupational health within the public health agenda. These will inform the strategic positioning of occupational health within the emerging health economy in order to achieve national policy objectives and outcomes. short term workforce issues for the NHS in achieving the QIPP agenda and ensuring OH services are fit for purpose These issues will be further developed through a separate report and progressed through the Department of Health s Health and Wellbeing QIPP programme. During the workshop delegates broke into groups and discussed three key questions: What three things should be done to make education and training and career structures in OH more fit for purpose and to re invigorate the academic base? How do we ensure a closer match between workforce skills supply and future delivery models in OH? How can the OH profession be encouraged to speak with a common voice and exercise leadership on behalf of the profession? A range of evidence was collated in advance of the workshop to provide delegates with information about the OH workforce and materials that have already been published (See annex 3). BACKGROUND The issues to be addressed should be seen in the context of wider challenges for occupational health regarding scope, quality of clinical practice and training. Dame Carol Black s review of the health of 5

6 Britain s working age population 1 challenged occupational health to expand its role and to take its place within a broader, collaborative and multi disciplinary service, available to people entering work, seeking to stay in work or trying to return to work in the wake of illness or injury. To do this it must overcome historical detachment from mainstream healthcare, the focus only on those in work, uneven provision, inconsistent quality, a diminishing workforce with a shrinking academic base and a lack of good quality data. To date, many of these challenges remain to be met. It is clear that failure to do so will lead to the ultimate demise of the specialty. The potential savings from effective occupational health provision are substantial. Reducing working age ill health could save the United Kingdom 100 billion per year 2. The Boorman report 3 highlighted that reducing sickness absence levels in the NHS by one third would produce an estimated annual direct cost saving of 555 million. This has been incorporated into the QIPP agenda. There is a pressing need, therefore, to ensure that the occupational health workforce has the capacity and capability to deliver these savings. SUMMARY OF POINTS MADE BY DELEGATES AT THE WORKSHOP It was apparent that there is real concern that occupational health has not changed sufficiently to meet changed expectations. A number of factors probably explain this. The original raison d être of occupational medicine and occupational health was the protection of workers from occupational diseases. Improved occupational hygiene has diminished the numbers of such diseases, in many cases, although a combination of a historical legacy of hazardous workplace exposures and continuing exposures to certain harmful substances means that health risk management is still a fundamental aspect of practise. However, the benefits of occupational health interventions tend to be much longer term than in the past. This means that employers may be unwilling to meet the costs of interventions where benefits may be seen in societal terms rather than affecting the business bottom line. In the NHS, the contribution to the control of substances hazardous to health and other health and safety priorities remains important, particularly with respect to infectious diseases. Nonetheless, a forward looking occupational health has to address current agendas within the framework of the health and wellbeing of staff and its contribution to the ability of Trusts to deliver excellent patient care. In particular, provision of expert occupational health to medical staff has become an area of subspecialisation for NHS occupational health services. There is a need to redefine the role of occupational health within the health and wellbeing agenda and to determine the relative contributions to be made by occupational physicians, occupational health nurses and other members of an increasingly diverse occupational health team. This fundamental reappraisal will inform manpower planning, which should be needs based. It will also inform training requirements. There is not a clear career path for occupational health practitioners. Doctors and nurses may train in the NHS or in other industry sectors. There needs to be better definition of the role of junior occupational health specialists within the occupational health team and better planning to enable career development. It seems likely that this will only be possible by considering occupational health provision 1 Working for a healthier tomorrow: Dame Carol Black s review of the health of Britain s working age population. March TSO. 2 Healthy Lives, Healthy People: Our strategy for public health in England. 30 th November TSO. 3 Boorman S. NHS Health and Wellbeing Final Report. November DH. 6

7 at a regional level, rather than a purely local level, giving opportunities for sub specialisation and leadership roles. Training in occupational health would, therefore, prepare the specialists of the future for an evolving role within the NHS that would offer opportunities to progress in a population focused or patient focused direction. There would also be a continuously developing management expertise to equip specialists to move from local service management to the management of large regional services. Developing a vision of the ideal occupational health team would involve defining the numbers of doctors and nurses required for a given population. This would be accompanied by structural changes that would see realignment of occupational health services into larger units. A literature review that was performed to assist the discussions during the workshop 4 indicated that a ratio of one specialist (consultant) occupational physician per 13,000 staff might be appropriate, based on estimates from the Faculty of Occupational Medicine. The precise ration would depend on the workplace hazards and risks. However, occupational health services covering a population of 40,000 to 50,000 staff would seem to be of sufficient size to offer the scope for specialisation and the provision of suitable training environments for doctors and nurses. It would also offer possibilities to participate in research and audit to underpin evidence based practice and contribute to the strengthening of the currently weak academic base. A number of suggestions were put forward for strengthening the academic base, with respect to both training and education and research. It was felt that this would make the specialty more attractive to new recruits, as well as enhancing the credibility of the specialty. Developing links with universities was felt to be critical step. It was proposed that all universities that train healthcare staff should include at least one lecturer in a relevant occupational health discipline. This might be a part time or even an honorary position and could be attractive to newly retiring practitioners with appropriate teaching experience. Training of occupational health specialists should include links to other specialties. A core curriculum for anyone working in occupational health needs to be developed to be delivered by higher education or further education establishments. It should form part of all uni disciplinary curricula and interprofessional training should be encouraged. Funding of training should come via Health Education England, with contributions from all employment sectors coming from an employer levy. This would facilitate cross sector and cross discipline training. Health Education England should also consider funding a number of lecturer posts to boost the delivery and quality of occupational health training. A recurrent theme was the need to address workforce planning for the working age population and not just for the NHS workforce. In addition, there was a developing vision of occupational health being provided from within the NHS for both the NHS workforce and a non NHS workforce. Two potential models of delivery were put forward: 1. Clinical Delivery commissioned by the NHS Commissioning Board. There would regional delivery through the NHS delivered to national standards. 2. Delivery through Public Health. Integrate occupational health with public health and deliver through Public Health England. The NHS Commissioning Board has a key role to play and the challenge is to ensure that the Board is aware of and understands the case for including occupational health within its commissioning remit. There is a role for occupational health leaders to make this case and to explain the return on investment. However, we also have to address the extent to which less specialised health and work services will be commissioned locally rather than centrally. 4 Future of Occupational Health Workforce: Evidence scope. (A Baker) 7

8 Of course, the NHS Commissioning Board only has a remit for commissioning on behalf of the NHS. Further work would be required to develop a method of funding service arrangements that go beyond the NHS. Options include a fee for service, as currently exists in a piecemeal fashion, a core service funded by an employer levy probably on a per capita basis or partnership working between the NHS and industry associations, such as constructing for better health. This would not preclude organisations funding their own occupational health services. Larger organisations may still wish to do this, although the trend has been towards outsourcing. In some cases, this works well; in others this method of providing occupational health has been less than satisfactory. A problem that needs to be addressed in this regard is the current level of awareness and understanding of occupational health by commissioners. A major initiative is needed to educate commissioners about occupational health, the need to invest in the health and wellbeing of the workforce and how to do it. Public Health England has a potential role to ensure that occupational health is included as part of the regional health and wellbeing agendas being commissioned via health and wellbeing boards. The move to a regionally delivered occupational health provision would be consistent with the drive for realignment of NHS occupational health services, as described in Healthy Staff, Better Care for Patients. It would also facilitate the inclusion of occupational health within developing integrated care provision by the NHS. This is considered by many to be essential if the NHS is to provide cost effective healthcare to an ageing population. In addition to the traditional workplace health risk management that has been the bedrock of occupational health, there should be a focus on health promotion and the prevention (primary, secondary and tertiary) of non communicable (long term) conditions, as well as occupational / work related illnesses. The promotion of work ability will be a key role for occupational health, to permit people to be able to work effectively until they choose to retire. This will require: influencing workplace cultures that encourage healthy behaviours amongst the workforce and, potentially, their families; the early detection of disease markers indicating the need for health interventions and support for people who develop illnesses that affect their ability to carry out their jobs, and rehabilitation back to work for workers absent due to illness. The contribution NHS occupational health services could make to the proposed sickness absence assessment centres 5 is significant and merits elaboration. Future population centric workforce planning for NHS occupational health should take account of the needs of the NHS, as an employer, and the needs of the NHS to improve England s public health. Population health needs and new models of delivery of occupational health will be important considerations in estimating numbers of staff, effective skill mix and requisite competencies. How can these essential changes be taken forward? There was a clear view that occupational health must engage with change and must be able to speak with one voice to communicate the vision and the benefits of change. The importance of leadership from within the specialty cannot be understated. Occupational health has become increasingly fragmented and it could be argued that a significant contribution to the current leadership has come from outside the specialty. Thus, as a specialty we are being pulled along, rather than pushing to create our own destiny. Clarity of purpose is essential. What 5 Health at Work An independent review of sickness absence. Dame Carol Black and David Frost CBE. Nov ISBN:

9 is the added value of occupational health and what difference does it make to people, organisations and communities? There is a need to ensure a growing awareness of the occupational health impact on the performance of organisations and on the quality of services? This is a message that must be delivered by authoritative and credible leaders now and in the future. We must be able to recruit high calibre trainees to the specialty if we are to provide our leaders of tomorrow and we must ensure that we train and support our existing workforce to enable them to assume leadership positions. The need for a common voice was deliberated upon and no single solution was proposed. One option put forward was the Council for Work and Health, a multi professional body established in the wake of Working for a Healthier Tomorrow. An alternative proposal was the coming together of the Faculty and Society of Occupational Medicine in the form of a new Royal College of Occupational Health. What is clear is that there is a compelling need for a body that will exert strong leadership to deliver the envisaged changes in occupational health and to communicate effectively with other key stakeholders, including the public. In particular, the weak academic base must be addressed urgently. Without such academic support, the specialty will cease to exist. Comparison was made between occupational medicine and general practice, where, over the last decade, the numbers of professors in general practice has risen considerably. A similar change in occupational medicine / occupational health would require a policy change that mandated the teaching of occupational medicine to medical students by suitably trained lecturers, similar teaching of occupational health to other occupational health practitioners and the development of an evidence base to underpin effective occupational health practice. Current leaders, both academic and professional, have to communicate effectively why such a policy change is necessary. 9

10 NEXT STEPS This section sets out actions to be taken arising out of the workshop discussions and identifies owners of the actions. The actions are summarised in tables relating to the three original questions being addressed. Background information about the roles of the action owners may be found in annex 2. What three things should be done to make education and training and career structures in OH more fit for purpose and to re invigorate the academic base? MAKING EDUCATION & TRAINING AND CAREER STRUCTURES FIT FOR PURPOSE To engage with Health Education England regarding funding for academic and training posts WHAT WOULD SUCCESS LOOK LIKE? Rotational training posts in occupational medicine, occupational health nursing, occupational health physiotherapy and occupational therapy providing high quality training in a variety of workplaces (NHS and non NHS) All universities that train healthcare staff should have at least one lecturer in relevant occupational discipline (this could be a part time or honorary position Streamline the implementation of training curricula to remove unnecessary bureaucratic barriers to establishing training posts and the quality management of training. OWNER (Stakeholders) Department of Health Faculty of Occupational Medicine (Council for Health and Work, OH professions) Agree a core curriculum for anyone working in OH with a clinical background and ensure delivery of training. Core standard training for nonspecialist OH practitioners coupled with discipline specific modules Deliver via HE and FE establishments Training (addressed through employer levy) Cross sector Cross specialty Council for Health and Work Faculty of Occupational Medicine Address recruitment and retention challenges for OH. Increased number and quality of healthcare professionals wanting to come into OH by including OH in basic Department of Health 10

11 Address positioning of occupational health under the public health umbrella and its relationships with primary and secondary care. REINVIGORATE ACADEMIC BASE doctor, nurse, physiotherapy and occupational therapy training Numbers of specialist and generalist OH practitioners sufficient to meet workforce needs. Market OH describing the potential for career development and subspecialisation. Work as a clinical outcome of healthcare episodes Influence health and wellbeing whole of the potential working population, not just employed workers Representation on and engagement with all Health and Wellbeing Boards re the 2 items on the Health Agenda o Management of long term health conditions o Long term sickness absence Occupational Health research/academic base linked with other specialities Increased funding of outcome based workplace centred occupational health research by major grant awarding bodies, such as NIHR, MRC and ESRC. Council for Health and Work (Faculty / Society of Occupational Medicine, Department of Work and Pensions) Council for Health and Work (Faculty / Society of Occupational Medicine, Department of Health) Council for Health and Work Faculty of Occupational Medicine 11

12 How do we ensure a closer match between workforce skills supply and future delivery models in OH? HOW DO WE ENSURE A CLOSER MATCH BETWEEN WORKFORCE SKILLS SUPPLY AND FUTURE DELIVERY MODELS IN OH? Develop new models of service delivery in the NHS WHAT WOULD SUCCESS LOOK LIKE? Reconfiguration of NHS occupational health services in line with current guidance 67. Two further possible models have been proposed and require further elaboration. 1. Clinical Delivery commissioned by the NHS Commissioning Board. Regional delivery through the NHS delivered to national NHS standards. 2. Delivery through Public Health. Integrate OH with public health and deliver through Public Health England. In addition, future models should explore: partnership working with primary care and the potential to develop GPs with a special interest in occupational medicine; the potential to develop the Health4work advice line as a first line triage and support service CCGs to commission less specialised services at a more local level services that might be provided in a way analogous to the Fit for Work Service pilots or might be delivered by GPs with a Special Interest. Ability of GPs to refer their patients for occupational health assessments. OWNER (Stakeholders) NHS Plus / Health at Work Network (NHS Employers, Department of Health, Faculty / Society Occupational Medicine, Royal College of General Practitioners) 6 Healthy Staff, Better Care for Patients: Realignment of occupational health services to the NHS in England. DH July A Short Guide to The Future Consolidation of NHS Occupational Health Services. NHS Health at Work. idation_of_nhs_oh_services_final_draft_version_27_march_2012.pdf 12

13 Develop and extend multidisciplinary service provision Population centric workforce planning A framework that defines an exemplary OH service and the specific skill mix needed for a given population. This will describe workforce components and roles of specific team members in delivering the health and wellbeing agenda and supporting the paradigm shift in occupational health. Future clinical occupational health teams will comprise a mixture of some or all of: Consultant (specialist) occupational physicians Associate specialist and staff grade doctors in occupational medicine Doctors in specialist training in occupational medicine Specialist occupational health nurses Non specialist occupational health nurse practitioners Occupational health nurse trainees Occupational health technicians Occupational health physiotherapists Occupational therapists Accredited counsellors and/or clinical psychologists Health coaches This will be according to local needs and model of service delivery. This model adopts a change management approach and involves key people looking at the workforce from a future based, service user needs perspective. Stakeholders, including service users, will undergo a process of: looking at the health and wellbeing needs of the service users in ten years time looking at the services required to meet those needs identifying which of these services should be provided within occupational health. Council for Health and Work (NHS Plus / Health at Work Network) Centre for Workforce Intelligence Department of Health (NHS Employers NHS Plus / Health at Work Network, Faculty / Society Occupational Medicine) 13

14 How can the OH profession be encouraged to speak with a common voice and exercise leadership on behalf of the profession? HOW CAN THE OH PROFESSION BE ENCOURAGED TO SPEAK WITH A COMMON VOICE AND EXERCISE LEADERSHIP ON BEHALF OF THE PROFESSION? Single voice Strong communications Strong academic base WHAT WOULD SUCCESS LOOK LIKE? A common body that will promote the vision for occupational health practice in the twentyfirst century and will take forward an influencing strategy to achieve accessible best practice occupational health for the whole of the working population. A new authoritative and credible standard setting body to speak for the various disciplines working within occupational health on areas such as training and education, research and clinical practice. Outward facing voice to the public, employers and Government. Strong leadership and courageous change agents: Credible senior leaders Policy and needs based Effective communications strategy that will market occupational health A specialty without a strong academic base ceases to be credible. A coalition of academic occupational health practitioners and academics with an interest in workplace or work related research produced strategy for the growth of academic occupational health. E.g. 10 years ago there were no professors of GP and this has been successfully changed. OWNER (Stakeholders) Council for Health and Work Council for Health and Work Council for Health and Work Faculty / Society Occupational Medicine 14

15 CONCLUSION The workshop has identified a range of issues to be addressed and has selected a number of key actions to be taken forward. There was considerable energy and enthusiasm for change amongst the participants, many of whom are in key positions within their respective organisations to influence further action. It is important that the momentum generated by the workshop is not lost. The aim of the workshop was to consider the medium to long term workforce issues for occupational health and the positioning of occupational health to support the health and wellbeing agenda. The actions required indicate a direction of travel for occupational health and the first steps to be taken on the journey. However, it is a route map rather than a journey planner. Further work will be necessary for the identified owners working with a wider stakeholder group to add detail and timescales to the plan that will describe specific objectives and the methods of achieving them. There is a need to establish an occupational health forum, similar to the DH Future Forum that will bring together leaders and stakeholders to work on the suggested actions in a time limited project. The themes emerging from the discussions about actions suggest a number of work streams that should be carried out in parallel, albeit they inter link and aspects of the work may be contingent on the outcomes from other work streams. A clear message from the workshop was that the time available to address change is short. The proposed changes in healthcare commissioning, and in training and education, present opportunities for occupational health. However, if they are not grasped, there is also a real risk that the specialty may disappear. John Harrison Director NHS Plus. 15

16 ANNEX 1 WORKSHOP ATTENDEES 16

17 Adrian Baker, NHS Plus team Ali Hashtroudi, NHS Health at Work Network Board member Amanda Hinkley, NHS Health at Work Network Board member Amanda Howe, RCGP Andrew Gilbey, NHS Plus team Anne de Bono, NHS Health at Work Network Board member Barry Lane, NHS Health at Work Network Board member Becky Farren, DH Dame Carol Black David Maslen-Jones NHS Health at Work Network Board member Diana Kloss, Council for Work & Health Chair Fiona Page, NHS Health at Work Network Board member Geny Foster, COHPA Chair Geoff Dessent, DH Helen Kirk, RCN Helena Johnson, CSP Council Chair Henry Goodall, SOM President Ian Aston, Director of Training, FOM Ira Madan Sarah Faulkner, Centre for Workforce Intelligence Jane Rook, NHS Institute John Chisholm, RCGP John Harrison, NHS Plus team Julian Topping, NHSE Karen Swann, NHS Health at Work Network Board member Keith Johnston, NHS Plus team Paul Litchfield, BT Richard Preece, NHS Plus team Ruth Warden, NHSE Selena Gray, Faculty of Public Health Sian Williams, HWDU Steve Cordes, DH Vanessa Hebditch, NHS Plus team 17

18 ANNEX 2 BACKGROUND ROLES OF AND INTERRELATIONSHIPS BETWEEN THE OWNERS OF ACTIONS 18

19 1. Council for work and health The Council represents a wide range of stakeholders 8 and is well placed to take forward strategic change management and to speak on behalf of its member organisations. It has been identified as the owner of a number of actions by the workshop, reflecting its unique leadership position within occupational health. It should develop a clear communications and marketing strategy for occupational health that integrates and is synergistic with the communications strategies of its member organisations. In the short to medium term it is in a position to provide a single voice for a multi disciplinary occupational health and to engage with organisations, such as Health Education England and the Department of Health regarding improvements in training and the positioning of occupational health under the public health umbrella and with regard to the health and wellbeing of the working population. It can also play a key role in facilitating the development of service delivery models and workforce planning through its stakeholder groups. As a matter of urgency, it needs to establish a coalition of academic stakeholders to develop and implement a strategy for revitalising the occupational health academic base. For the longer term it should address the need for a national standards setting body for the whole of occupational health which will be important as part of the strategy for revitalising the academic base. 2. The Faculty of Occupational Medicine (FOM) as the standard setting body in the United Kingdom for occupational medicine, the FOM has a key role to play in promoting change in the training of occupational physicians and revitalising the academic base of occupational medicine. It can utilise links with the Deanery network and the General Medical Council (GMC) to address concerns about current training arrangements. It can approach HEE directly on behalf of occupational medicine or as part of the Council for Work and Health on behalf of occupational health. As a member of the Academy of Medical Royal Colleges it can champion the need for inclusion of occupational health in core medical training. It can utilise its links with the Department of Health and the Department of Work and Pensions to influence the future delivery of occupational health and manpower planning. 3. The Society of Occupational Medicine (SOM) The SOM is a professional membership organisation that promotes continuing professional development and, through its regional structure, has a substantial reach to practising occupational physicians and, now, occupational health nurses. In addition, its membership includes general practitioners and other clinicians with an interest in work and health. Its appraisal system will play an important part in the revalidation of occupational physicians. Its specialist committees play an important part in maintaining and improving standards of practice

20 Working on its own and in collaboration with the FOM and the Council, it is well placed to address issues pertaining to training, clinical practice and workforce demographics. 4. NHS Plus / NHS Health at Work Network NHS Plus was a DH funded project that aimed to improve the quality of NHS occupational health services, assist the NHS become an exemplar employer and extend the provision of NHS occupational health to small and medium sized enterprises (SMEs). The NHS Health at Work Network was established to ensure the sustainability of the NHS occupational health services network created by NHS Plus. NHS Plus is delivering a range of projects addressing quality of NHS occupational health provision, reconfiguration of services and workforce planning. Implementation occurs through the network. It is also addressing the positioning of NHS occupational health. Key stakeholders are NHS Employers and the Department of Health, as well as with the Faculty and Society of Occupational Medicine and the Council for Work and Health. 5. NHS Employers NHS Employers is part of the NHS Confederation and is the voice of employers and workforce leaders in the NHS. It has a focus on workforce issues, which includes health and wellbeing of staff. NHS Employers has worked closely with NHS Plus on producing guidance on the commissioning of occupational health services and on delivering the health and wellbeing agenda. 6. Government Departments Two government departments have a stake in the development of the occupational health workforce The Department of Health and the Department of Work and Pensions (DWP). Within the Department of Health, the Workforce and the Health Improvement Directorates consider the health and wellbeing of NHS staff as relevant to implementation of government policy and have a key role to play. The workshop has highlighted several areas that DH workforce should take ownership of and lead change. Welfare reform is an important driver of policy for DWP requiring sufficient capacity of the occupational health workforce to support changes in sickness absence management. The departments have a facilitative role in developing and taking forward strategies to change occupational health delivery and capacity. 7. The Royal College of General Practitioners (RCGP) The RCGP is concerned with improving the occupational health advice available to patients. Many GPs feel inadequately trained to deal with workplace issues even though they are usually the first person to see patients who may be unfit for work. The interface between GPs and occupational health practitioners is an important one. There is the potential to increase the capacity of occupational health and accessibility to occupational health advice for patients by improving training of GPs and primary care staff and developing a supervised framework of practice, whereby GPs could be supervised by consultant occupational physicians. 20

21 8. Centre for Workforce Intelligence (CfWI) The CfWI provides an easily accessible route for health and social care planners, clinicians and commissioners seeking workforce planning and development expertise to improve health and social care services. It supports long term and strategic scenario planning for the whole health and social care workforce, based on research, evidence and analysis, in order to build strong leadership and capability in workforce planning. 21

22 ANNEX 3 FUTURE OF OCCUPATIONAL HEALTH WORKFORCE: EVIDENCE SCOPE 22

23 FUTURE OF OCCUPATIONAL HEALTH WORKFORCE: EVIDENCE SCOPE Adrian Baker Introduction Perhaps the most major recent shifts in occupational health (OH) have been the move towards the biopsycho social model of care and the increasing use of evidence based medicine. These two shifts are grounded changes they provide the foundation for the way OH professionals interact with their patients and are unlikely to be changed by systemic changes. Occupational health has always faced internal and external pressures, such as the change in predominant OH conditions spurred by the decline of the manufacturing sector and growth of the service sector and it has always adjusted accordingly. However, these adjustments have always given an air of reactivity rather than foresight. With an aging OH workforce, changing patient demographics, and changes to the retirement age, OH has little choice but to be pro active in the way it will deal with these issues, as reactive measures will be too little, too late. Perhaps now more than ever, OH is pushing at a relatively open door. The emerging social and political recognition of the costs of sickness absence and presenteeism as well as the role better health and wellbeing can have in delivering the productivity gains desperately needed by the NHS may give the green light to develop bold and ambitious policies for the OH workforce. What, therefore, can the literature provide by way of answers to the challenges facing OH? How can there be evidence for policies on challenges that have not yet occurred? Is there any evidence that can help guide or inform policy? Through an informal scope of the literature including a brief literature search 9, this document provides a summary of some key issues. The questions considered were: How can OH recruit and train a future workforce? Do OH professionals do jobs that no other healthcare professionals can do? What are the key OH workforce issues in other countries? How can OH meet the challenges of changing demographics? Not all these questions were answered through evidence, and neither was the evidence particularly strong or convincing, but studies and papers were nonetheless included to raise debate. A more detailed literature search may produce deeper analytical insight into these issues, offer greater examples from outside OH, and can include new issues such as the utilisation of new technology (such 24 hour monitoring devices). 9 Pubmed: occupational health[title] / limits (5 years, English) =

24 Are specialist OH physicians and nurses needed? One of the debates surrounding the OH workforce, or indeed any other specialist workforce, is whether (and if so how much) added value do the specialists provide over and above non specialists. Though this has not been directly or adequately answered in the literature, studies have attempted to offer evidence as to the intrinsic, if not comparative, value of the OH workforce. In one particular study, 373 Finnish OH nurses returned a questionnaire on what they considered were the activities, features, prerequisites and consequences of their OH expertise (Naumanen, 2007). Their activities included working with employees and employers, working with other stakeholders, and administrative and office work similar to OH nurses in other countries. They believed that the main benefit of this expertise was increased health and reduced number of work related health risks. Whilst the respondents believed that knowledge, skills, experience and competence were important elements of expertise, they also believed that a well groomed appearance, good health and a positive attitude were also important elements of their expertise (see Tables 1 and 2 below). The study proclaims that the work of OH nurses can benefit employers, employees and their OH units, but that more research is needed to demonstrate their relative importance. The author stresses that OH nurses need to allocate more time to preventative care, and suggests that continuing professional education should be focused on preventative elements, such as workplace health promotion, risk management and economics all of which will better respond to client needs. Table 1 Features of OH nurses' expertise linked to their position (Naumanen, 2007) 24

25 Table 2 Prerequisites for OH nurses' expertise linked to their professional education (Naumanen, 2007) In another Finnish study, Kimanen et al (2011) analysed the work and health related factors associated with primary care visits to OH physicians and OH nurses in Finland. It was a cross sectional survey of 1636 randomly selected working employees covered by occupational health services and primary care. The proportion of employees that visited OH physicians and nurses was 57%. The factors most associated with visits to OH were type of OH service provision, long standing illness effecting work, and work related symptoms. Obtaining a sick leave certificate was associated with visits to OH amongst men. Stress was only associated with visits to an OH physician, and not with visits to an OH nurse. Severe stress symptoms were not associated with visits to either OH physicians or nurses (another study of the Norwegian police force showing that visits to GPs were more common than for OH with relation to mental health issues). Poor support from co workers and line managers had an inverse association with visits to OH, although having a weak ability to influence one s work was associated with visits to OH. The most direct attempt at a comparative analysis of the added value of specialist OH professionals is the Faculty of Occupational Medicine (2012) paper outlining the future need for consultant occupational physicians. The paper aims to inform the FOM s strategy on the number and roles of OH physicians, although the discussion on the comparative value and the estimates of numbers needed are largely based on assumptions. The paper outlines some of the professional groups that help to deliver OH in the UK. These include: Non specialist OH physicians (such as GPs who carry out relevant OH work or who have a DOccMed) OH nurses OH technicians Occupational hygienists Ergonomists Safety professionals Physiotherapists Occupational therapists Occupational psychologists GPs working in primary care Physicians specialising in disability assessment and rehabilitation 25

26 Other specialist physicians (such as dermatologists) Addiction specialists Counsellors Training between these groups is varied: some of the groups have rigorous and standardised training, whilst the training for other groups is much more diverse. Pay is meant to reflect the differences in both skills and training. Accordingly, the paper makes a case for the value added of specialist OH physicians by outlining the particular skills and competencies they argue are not possessed by other OH groups to the same combination and extent. These skills and competencies include: Broad medical knowledge whilst this broad medical knowledge is shared by other doctors, it is wider and more detailed than OH nurses or non medical OH professionals. Specialised knowledge and skills concerning the inter relation of work and health whilst some OH groups have skills and knowledge in specific areas that extends further than that of specialist OH physicians (e.g. ergonomists), and whilst other OH groups share the same breadth of knowledge as specialist OH physicians (such as OH nurses and GPs), no group has the full breadth and depth of skills and knowledge possessed by OH physicians. Familiarity with workplaces and the organisation of employment the knowledge of health and safety law, employment legislation, working environments and organisational structures is more detailed than other doctors and OH professionals. Skills in health promotion whilst OH nurses can be equally skilled in the area of health promotion, health promotion tends to fall outside the scope of other OH professionals. Scientific knowledge and understanding specialist OH physicians possess a broad knowledge of a number of different scientific areas, with some possessing in depth expert knowledge. As with specialised knowledge and skills concerning the inter relation of work and health, some groups may possess equally in depth knowledge in some of these areas, but no other group possess the same depth and breadth as specialist OH physicians. Independent decision making whereas other groups have analytical and decision making skills, no group as a whole possess the extent to which these skills are evident in specialist OH physicians. Leadership in conjunction with independent decision making, specialist OH physicians possess leadership skills through their training in management of organisations and staff. However, leadership skills can be found in other OH professions, and not all specialist OH physicians possess good or unique leadership skills. However, whilst this paper outlines the possible added value of specialist OH physicians, it does not give a good indication of the extent of this added value, in comparison to each group systematically, nor does it give an indication as to how much training is required in each of these aspects for each group to possess the same knowledge and skills. For example, whilst health promotion is stipulated as an added value of specialist OH physicians that is not possessed by any other group barring OH nurses (at least, to the same extent), there is no indication as to what, e.g. non specialist OH physicians, will have to do to possess the same knowledge and skills of health promotion. There is also no indication as to whether such training would be cost effective, whether it would be cost effective for some groups and not others, whether it would be cost effective for some areas and not others, and whether specialist OH physicians would, in this sense, be more cost effective than the sum of all parts, and whether they 26

27 provide extra value when summing all parts. Nevertheless, the paper argues that only the skills possessed by specialist OH physicians can be utilised in a number of circumstances: Complex occupational hazards managing work situations that provide particularly complex issues that cannot be dealt with using pre defined procedures. For example work in extreme climates or involving risks such as cyanide poisoning. Such situations are beyond the remit of other OH professionals. Complex health impacts on fitness for work specialist OH physicians are required to deliberate on the fitness of employees for working in areas with risk to the worker or wider public (e.g. flying or public transport), or for working in areas where decision on fitness for work can have major financial, social or political implications. Such decisions are not always straightforward, and have to be defensible against potential legal challenges. Care of workers with special medical knowledge specialist OH physicians may be required to make decisions on and give OH advice to those working in other medical and health professions. The knowledge and skills of a specialist OH physician would allow them to garner the trust and confidence of those with special medical knowledge. Environmental health hazards associated with industrial activities certain employers, such as chemical plants or those working in the electricity industry, may require advice on risk management for both their employees and the general public. Specialist OH physicians are able to assess and communicate such risks to these employers and relevant stakeholders, and are able to defend their assessment against scrutiny. Leadership the training required to be a specialist Oh physician means that they are able to take on management duties or help develop guidance that can be followed by others. Research the depth and breadth of broad and specialist medical knowledge, as well as training in collaborating on research projects means that specialist OH physicians are well placed to conduct OH research and identify key areas where research is needed. Training whilst not all the training required to become a specialist OH physician needs to be provided by a senior colleague, the skills, knowledge and experience of specialist OH physicians means that they are needed to train new recruits, as well as train other groups of OH professionals. Given the application of skills held by specialist OH physicians, the paper provides estimates for the number of specialist OH physicians needed in the next 5 10 years (see Table 3). Although the paper adds the caveat that there are uncertainties in its estimates, it argues that OH will unlikely experience in the next ten years anything like the developments it experienced in terms of sectoral change within the economy or the move from in house provision to contracted out services. The estimates are provided for certain sectors, although the paper suggests that all sectors may benefit from the skills of specialist OH physicians. Additionally, the estimates are based on a survey of FOM Members and Fellows with 68% response rate, and assume that services are provided efficiently, though the estimates do not assume where the specialist OH physicians are employed. 27