NHS occupational health services in England and Wales a changing picture

Occupational Medicine 2003;53:47 51 DOI: 10.1093/occmed/kqg008 NHS occupational health services in England and Wales a changing picture A. Hughes, R. Philipp and C. Harling Introduction Aims Method Results To establish the extent of doctor input to occupational health (OH) service provision in the UK National Health Service (NHS) in 2001 and to compare this with inputs in 1998. A postal questionnaire was used to obtain information from OH medical staff employed by the NHS in England and Wales. The NHS OH service has seen an increase between 1998 and 2001 in the amount of doctor time per employee. Doctors tend to work now for more sessions per week. The proportion of doctors holding specialist qualifications has also increased. An increased number of NHS employees now have access to consultant care for occupational medicine. OH departments increasingly tend to provide services to employees beyond the NHS and are thereby able to generate income to further the development of the service. Conclusions Steady progress is being made in improving the provision of OH services within the NHS. However, substantial variation exists in the apparent level of access to such provision. The government policy for all NHS staff to have access to a consultant-led service is not yet met. NHS Plus will impact on this picture and deserves study in the future. Key words Received 7 May 2002 NHS; NHS Plus; occupational health services; staff. Accepted 30 October 2002 In earlier work on UK National Health Service (NHS) occupational health (OH) services [1], we identified the patterns of staffing and provision of NHS OH services based on a 1998 survey of all NHS Trusts in England and Wales. There were substantial inequalities of access to OH services for NHS employees. The findings suggested a wide diversity of the ways in which departments worked. Only one-third of the workforce were likely to have access to a consultant occupational physician, despite expressed government policy. In early 2001, we revisited these questions as part of a second survey commissioned by the Association of Centre for Health in Employment and the Environment, Avon Partnership NHS Plus, United Bristol Healthcare NHS Trust, Whitefriars Centre, Lewins Mead, Bristol BS1 2NT, UK. Correspondence to: Anthony Hughes, Centre for Health in Employment and the Environment, Avon Partnership NHS Plus, United Bristol Healthcare NHS Trust, Whitefriars Centre, Lewins Mead, Bristol BS1 2NT, UK. E-mail: anthony.hughes@ubht.swest.nhs.uk National Health Occupational Physicians (ANHOPS) and the Department of Health (DoH). ANHOPS were interested in whether they were reaching the group of doctors that they represent and the DoH were about to launch their development plans for NHS Plus and required background medical staffing information. This paper has taken core data sets from 1998 and 2001 common to the two surveys and attempts to determine whether the OH services of the NHS in England and Wales are responding to the challenges set out in guidance issued by the NHS Executive [2]. Method A mailed questionnaire was sent addressed to the Occupational Health Department in each of the English and Welsh NHS Trusts and Health Authorities (HA) listed by the Department of Health in January 2001. Where our 1998 survey database had a detailed name and address for the OH service of the same Trust, this was Copyright Society of Occupational Medicine. Printed in Great Britain. All rights reserved. 0962-7480/02 47

48 OCCUPATIONAL MEDICINE used instead of the general address. The questionnaire in 2001 sought information only relating to medical (physician) staff working in the department. It did not, as in 1998, ask also about nursing services within OH departments. The information requested included name, grade, qualifications (relevant to OH), age and number of weekly sessions (half days of employment) given by each doctor to that Trust. In addition, respondents were asked about the extent of the work they undertake within the department for non-nhs groups/organizations and to indicate the type of organization concerned. Reply envelopes were provided with each mailing and a data collection period of 3 months was allowed after mailing for return of completed questionnaires. Funding constraints did not permit reminders to be sent to individual Trusts. After data had been collated, telephone enquiries were made regarding whether an OH department existed in the 27 Trusts from whom replies had not been received in both 1998 and 2001. Results The mailing in 2001 went to 370 Trusts and 103 HA. We were aware from our 1998 data that it is not usual for HAs to have their own in-house OH service and therefore anticipated a general lack of response from HAs. The actual response rate for HAs was 35% (36/103). None of these HAs had their own service. Replies were received from 244 of the 370 Trusts approached, a response rate of 66%. However, in 90 (37%) of these Trusts, their OH requirements were provided by a neighbouring Trust and not within their own organization. A data set of 154 OH departments was therefore obtained from this second survey. To improve the estimate of the actual number of OH departments presently in the NHS, data were amalgamated from the two surveys. We were aware that there had been changes in Trust organization between 1998 and 2001. Some renaming had occurred and several mergers had taken place. We recognized the need to report the existence or non-existence of an OH department in any Trust that responded to either the current survey or to our previous work (having allowed for any change of name/merger). Using the January 2001 DoH website list of Trust names, this accounted for all but 27 Trusts. We undertook telephone enquiries of these institutions to identify whether or not there was an in-house OH department. We concluded that OH departments could be found in 236 (of the 370) Trusts but could not be found in the remaining 134 Trusts or the 103 HAs. Thus, 64% of Trusts were providing an in-house OH department in 2001. Findings presented in the remainder of this paper are for data from 154 Trusts with OH departments, representing a 65% sample of the actual departments. We cannot determine if this sample is truly representative of all departments. Nevertheless, since our methodology was fundamentally similar in 1998 and 2001, we believe it is possible to undertake reasonable comparisons over this time period. Our 1998 survey reported on 198 departments from an estimated response rate of 68%. This is very similar to the 66% response rate in 2001. There was no indication from comparison of 1998 and 2001 data that non-response was geographically distributed or related to the size of Trust. Although the number of surveyed Trusts with OH departments fell by 44 (22%) between 1998 and 2001, this is close to the proportionate reduction of 455 Trusts in 1998 to 370 in 2001 (a fall of 19%). In 1998, there were 362 doctors in responding departments. It might be anticipated that in 2001 there should be 22% fewer, i.e. 362 80 = 282 doctors. There were in fact (Table 1) only 236 responding doctors, which might suggest a 16% fall in medical personnel in OH over the past 3 years. This figure is too large to be explained solely by response differences, but it will be shown that some of this change may be explained by other factors. There were two encouraging signs relating to the distribution of grades of medical staff employed in 1998 and 2001 in OH services. First, we identified a 50% increase in the proportion of consultant staff and a small increase in the proportion of specialist registrar grade employees. Concurrently, there were fewer clinical assistant posts and medical staff working in OH who held other hospital positions. Secondly, the numbers of doctors holding formal Faculty of Occupational Medicine qualifications (fellows, members or associates) had risen from 52 to 60%. The proportion of doctors working in OH without a declared OH qualification had also fallen by a third from 33 to 22% (Table 1). A finding of our 1998 study was that OH departments employed a large number of part-time doctors. This had changed by 2001, with a 50% increase in full-time posts. This finding could in part be an explanation of the apparent falling numbers of staff. Equally, the average number of sessions worked by the doctors had risen from 3.55 to 4.68 sessions/week (an increase of 32%). This more than compensates for the falling number of Trusts and suggests a 10% increase in real terms in the provision of medical sessions. Information available in the 2001 survey, but not for 1998, shows that although many of the doctors were part-time in an individual Trust, 62% of them were involved in OH work elsewhere. The only sizeable group that did not follow this pattern was the 21% of OH part-time medical staff who also work in primary care (Figure 1). Between 1998 and 2001, the structure of the departments changed (Table 2). It was apparent that in 2001 a higher proportion of departments were being run with

A. HUGHES ET AL.: NHS OCCUPATIONAL HEALTH SERVICES IN ENGLAND AND WALES 49 Table 1. Medical manpower in OH departments details for 2001 and, where possible, comparison with 1998 No. in 2001 Percentage in 2001 Percentage in 1998 Departments responding to survey 154 a Doctors employed in these departments 236 a Of whom: Consultant grade 97 41 27 SCMO grade 21 9 7 Specialist Registrar grade 31 13 10 Clinical assistant 42 18 31 Other hospital post 12 5 14 Other grades 33 14 12 Qualifications of employed doctors FFOM 40 17 15 MFOM 56 24 18 AFOM 44 19 19 Other OH qualification 43 18 15 No declared OH qualification 53 22 33 Working patterns of employed doctors Full-time 53 22 14 Part-time 183 78 86 Average sessions/week 4.68 a SCMO, Senior Clinical Medical Officer; FFOM, Fellow of Faculty of Occupational Medicine; MFOM, Member of Faculty of Occupational Medicine; AFOM, Associate of Faculty of Occupational Medicine. a In 1998, 198 departments responded, with a total of 362 doctors working 3.55 sessions/week on average. Figure 1. Work by occupational physicians other than for the employing Trust. only one doctor (69% in 2001 compared with 54% in 1998). More departments had a consultant in post, with just over half of the Trusts having reached this government policy target. Similarly, the level of qualifications of the most senior doctor in each department improved between 1998 and 2001, although the change was not substantial. Whilst the proportion of departments with a full-time doctor had fallen, there were more doctors undertaking from two to five sessions per week and fewer undertaking two or fewer sessions. As part of the planning for the introduction of NHS Plus, departments were asked about the diversity of the OH work they undertake outside the NHS. No strict definitions were applied to the categories of activity that might be undertaken and respondents were asked to use their own subjective judgement. Although set up primarily to support their working colleagues within the NHS, 84% of departments were undertaking non-nhs income-generating activities. This is a substantial increase since 1998, in terms of both the numbers of departments involved and the levels of such activity. Outside work on average represented 27% of financial turnover in 2001, up from 18% in 1998. As shown in Figure 2, much of this involvement was with industrial/commercial sectors, with companies of all sizes taking advantage of the available OH facilities. This is not to suggest that the more

50 OCCUPATIONAL MEDICINE Table 2. Medical staffing and work of OH departments: details for 2001 and, where available, comparison with 1998 No. in 2001 Percentage in 2001 Percentage in 1998 Departments responding to survey 154 a Departments who employ: One doctor 106 69 54 Two doctors 25 16 26 Three or more doctors 23 15 21 One or more consultants 87 51 44 One or more full-time doctors 41 27 38 Sessions of doctor time/week 2 or less 42 27 38 2 5 57 37 26 5 10 24 16 15 >10 31 20 21 Senior doctor holding: FFOM/MFOM 84 55 51 AFOM or Occ Diploma 48 31 31 No declared OH qualification 22 14 18 Undertaking non-nhs work 129 84 54 Which generates: b <10% of turnover 19 18 42 10 20% of turnover 24 22 20 20 30% of turnover 28 26 14 30 50% of turnover 29 27 15 >50% of turnover 7 7 9 a In 1998, 198 departments responded. b Only reported by 107 departments in 2001 and 106 in 1998. Figure 2. Occupational health services provided to outside organizations. traditional areas of local authority and public sector work were not undertaken, or that these were the more important as income generators. In 1998, OH departments served vastly different sizes of employee groups (ranging from 450 to 15 000). This had not changed by 2001. The variation was from the smallest department, serving 200 staff, to the largest, serving 16 400 employees. The average was 4930 employees (3700 in 1998), suggesting that OH departments are increasing in size. When this is related to the numbers of doctor sessions, the mean potential patient group had fallen from 1467 in 1998 to 1153 employees/session in 2001. However, the variation in these figures from 120 to 9200 patients/session across departments was still as large as ever. These findings support the claim earlier in this paper that the numbers of sessions of OH offered had increased and the numbers of potential patients to be seen in any individual doctor session had fallen. Discussion The NHS is adapting to change, as demands on all its components continue to increase. OH is no exception. Recognizing the link between employment and health and the adoption of a 10 year OH strategy in 2000, the Department of Health launched NHS Plus. This is intended to provide OH services to non-nhs employers, particularly small and medium-size enterprises. A key requirement of NHS Plus is that external services can only be provided if there is no detriment to the service provided to NHS staff. This survey in 2001 has shown that the work of the vast majority of OH departments already encompasses service delivery to organizations/ groups outside the NHS. This suggests that they should be able to provide the input required to meet the concepts of NHS Plus. These data suggest that this activity by NHS OH departments is already increasing. The 3 years from 1998 to 2001 have seen changes in the way OH departments are structured. Many of these must be viewed as improvements. Mergers of Trusts themselves and, in some cases, mergers of the OH departments have reduced the total number of service

A. HUGHES ET AL.: NHS OCCUPATIONAL HEALTH SERVICES IN ENGLAND AND WALES 51 providers. However, more departments, but not all, now have consultants in post. More doctors are working more sessions for their Trusts. These doctors are better qualified in OH and many undertake the OH function in settings other than their NHS trust environment. Slightly disconcerting is the failure to see a real strengthening of the number of doctors in training in the speciality. It can only be hoped that this will not compromise the continuing development of OH. This could provide an impetus to a critical evaluation of skills and roles of the different professionals working in OH. We are aware that this paper and our second survey have only looked at doctor inputs. It is acknowledged that OH is a multidisciplinary process and gains in medical inputs may not have been matched by progress in other crucial OH staffing provision. This study has shown that the NHS has not yet met its target of access to specialist OH services for all staff. The trend is in this direction, but a focus on this objective should not be lost. It is apparent that there remains great variation between Trusts in the numbers of OH doctor sessions per 1000 employees. This warrants still further detailed investigation before Trusts and their employees can feel confident that they are obtaining good value for money from their OH departments. Our informal enquiries suggest that OH departments tend to function in very different ways. However, it should be recognized that future staffing shortages may dictate a need for improved collaboration and changes in patterns of service delivery. Acknowledgements We thank all the OH departments and their medical staff who provided the information for this study. The study was supported by grants from ANHOPS and the Department of Health. The views expressed are those of the authors. References 1. Hughes A, Philipp R, Harling K. Provision and staffing of NHS occupational health services in England and Wales. Occup Environ Med 1999;56:714 717. 2. NHS Executive. Health Service Guidelines: Occupational Health Services for NHS Staff. London: Department of Health, 1994; 51.