Occupational health should be part of the NHSBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2334 (Published 23 May 2017) Cite this as: BMJ 2017;357:j2334
All rapid responses
HM Government has progressed plans for Occupational Health in the UK and a consultation process is underway. ‘Health is everyone’s business: Proposals to reduce ill health-related job loss’
The consultation acknowledges both evidence that early intervention by an employer for a sick employee reduces health related job loss and that at present there is little in the UK system to encourage employers to take early action during, or just before, the sickness absence period.
Changes are proposed by government to support employers and employees such as adjusting Statutory Sick Pay arrangements to better support a phased return to work.
The model for Occupational health delivery is unchanged. The consultation says ‘OH is largely provided commercially. There may be a role for government, and others, in ensuring that the market can respond effectively to increased demand with an increased supply of high quality and cost-effective services.’
Changes to enable better access to Occupational Health are considered in Chapter 3 ‘Occupational Health Market Reform’. The consultation considers how Government can subsidise OH provision for small and medium employers (SME), and the possibility of giving employees a right to request workplace modifications if unwell.
In the section ‘increasing the supply of high quality cost-effective services’ it says ‘to achieve this the market will need to respond in two key areas’
• innovation to support continuous quality improvement
• standards with scope to build on existing quality standards.
'The government’s view is that market forces alone are unlikely to be sufficient to respond to these challenges in a timely way.’
Improving capacity within the OH workforce is discussed with acknowledgement that Government intervention is likely to be required, including ‘longer term approaches to training and development of the workforce models’. There are no clear proposals about what form this might take, but ‘the government is interested in working with partners to encourage a significant increase in the number of OH specialists’. The questions in the consultation ask about private OH providers being more involved.
Government is interested in testing new ways of delivering services and ‘the government could dedicate funding to the development and testing of new models of buying and selling services.’ ‘Unlocking the full potential of the OH market to support employers and employees could reduce ill health-related job loss, improve business productivity, and potentially reduce pressure on the NHS’.
This consultation develops the purchaser provider model rather than more directly connecting Occupational Health to the NHS, and correspondingly to the NHS system for healthcare provision. Some additional Government funding is implied, both to support employers to buy Occupational Health and to support Occupational Health training within and outside the NHS. How much funding, and how this will work is not clear.
Government’s on-going engagement on work and health issues is encouraging. Change so that any employee with a health problem has a right to ask their employer to consider workplace adjustments would close a gap which has developed linked to disability legislation. The legislation has a tended to have the effect that employers look at adjustments only if an employee has a qualifying disability, rather than because they have a health condition that impairs their ability to work, but does not necessarily meet the criteria for a disability within the meaning of disability legislation.
Occupational Health delivery looks set to continue, as at present, with a commercial market model involving delivery by private providers and NHS Occupational Health departments who sell services in the same way as private providers. It is not clear how in practice this will make Occupational Health fully accessible to UK citizens of working age, and overcome the current concerns about manpower and recruitment of Occupational Physicians.
The consultation closes on 7th October.
Competing interests: No competing interests
In response to Paul Nicholson's rapid response, (1) I would like to give some details of the challenges affecting occupational medicine training.
All medical specialist training is expensive; the large majority of training takes place within the NHS and a small proportion occurs outside of the NHS (occupational medicine being one example). Currently occupational medicine training takes place in commercial organisations, Defence Services and the NHS. All of these training positions produce specialists who have the same set of core skills & knowledge to be able to act as an independent specialist in any organisation. Putting together the curriculum, and confirming that trainees have these skills, via examinations and other assessments is a core role of the Faculty in liaison with the General Medical Council (GMC).
Establishing any viable training position requires senior management commitment support and this means financial costs and a time commitment, but there are benefits from having a trainee; extra personnel for service delivery is the obvious one, but there is also the wider ethical benefit in continuing to produce tomorrow's specialists. The actual process required by the GMC for establishing a new position is complex, so the Faculty of Occupational Medicine (FOM) has produced step by step guidance to make the process as straight forward as possible for the employing organisation. (2)
The FOM, as with all other Royal Colleges, has no remit to establish training positions; this has to be a decision of the local or national employing organisation, whether this be a commercial, Defence Services, or for the NHS, Health Education England or National Education Scotland. However, the Faculty and its officers have had frequent meetings to lobby HEE Board and officers over the past four years and will continue regular dialogue in the future. The Faculty's role, along with the BMA, SOM and the National School of Occupational Medicine is to continue to present robust arguments to emphasize the need for more training positions.
The proposal in the editorial is to ensure occupational medicine is formally included within the NHS services and specialties, and to deliver advice not only to NHS employees but also to the local population. As a formal part of the NHS this would thereby ensure inclusion in the annual NHS workforce planning. It is recognized that inclusion within the NHS would require an increase in trained occupational health specialists which means that more training positions are required.
A meaningful debate about the sensible options to increase the number of training positions would be very valuable, and this would have to include the National School of Occupational Health, Health Education England, the BMA and representatives from Defence Services and commercial occupational health providers.
Dr Ian Aston
Faculty of Occupational Medicine, 2013 to 2016
2) www.fom.ac.uk/education/speciality-training/establishing-a-new-training-... occupational-medicine
Competing interests: No competing interests
The editorial which proposes that occupational heath services (OHS) should be part of the NHS  is wrong on so many levels. The problem is lack of access by UK workers to comprehensive OHS; this proposal does not guarantee to resolve that. Whenever faced with complex or major problems it is important to step back and take a systematic approach to problem solving. This involves first seeking to understand, not only the problems, but the also the causes, contributors and confounders; to discuss the potential solutions; and agree the best solution. From a quality perspective it is important to benchmark recognising that there are many models of delivery locally and globally; indeed countries such as the Netherlands which have had the highest rates of access to OHS achieve this through the private provision . In Europe very little OHS is provided from state health systems; what makes a difference is explicit legislation to mandate that employers provide workers access to OHS. Furthermore a quality approach would involve consultation with stakeholders prior to recommending what is the most immediately obvious, but not necessarily most effective solution.
An earlier editorial noted that UK occupational medicine is in demise . It was the BMA occupational medicine committee (concerned with the lack of effective action to address a long-standing and growing problem) which triggered the All Party Parliamentary Group report mentioned in the latest editorial. That report concluded differently; recommending that Health Education England, etc fund a model that meets the requirement for training posts and that Government and insurers explore how to best incentivise employers to provide workers with access to occupational health. As an objective response to this the Society of Occupational Medicine published a report to define the value proposition, synthesizing the evidence to help make the case for occupational health to various stakeholders .
The NHS isn’t an amoeba but a complex organism comprised of individual Trusts. It is naive to expect uniform delivery of OHS through the NHS against long-standing criticisms of post code delivery of health care and most recently neonatal death rates which vary by Trust. We know from BMA annual representative meetings that delivery of OHS to the NHS customer is patchy; indeed some NHS OHS, or parts thereof, have been outsourced to the private sector.
The authors are correct to point out that there are ‘just 74 trainees across the whole of the UK’. This is shameful compared to 154 trainees at the end of 2006 . The 2012 and 2013 Faculty reports both state that it ‘also redoubled efforts to attract new trainees’. Where is the evidence? Around that time considerable resources, staff time and over £140,000 of Faculty funds were tied up in a failed single organisation project . One wonders if the trainee dilemma would be different had these resources been directed to solving the most urgent priority.
Other problems that should be foreseen with the authors proposed model include that the NHS already faces a deep funding crisis; that investment in services depends on local commissioning; hence provision should not be assumed where there are more urgent health and social care priorities.
I agree that there is an urgent problem. I warned in 2004 ‘while the shape of business has changed, the shape of OHS largely has not. This together with growing manpower shortages, could widen the gap between the need for and the provision of OHS unless radical measures are taken. We should explore the potential for profound change….. Undoubtedly we must drive debate for the future of OHS if we are to close the substantial need supply gap meaningfully’ . So please let’s have that long overdue debate and explore what is best. Don’t rush in to make OHS part of the NHS. I suggest it is time for an independent inquiry to explore why we are where we are and to propose a sustainable, effective solution once and for all. Let’s start the debate here and now!
1. Torrance I, Heron R. Occupational health should be part of the NHS. BMJ 2017; 357: j2334
2. Nicholson PJ. Occupational health in the European Union. Occup Med. 2002;52:80–84. doi: 10.1093/occmed/52.2.80.
3. Raynal A. Occupational medicine is in demise. BMJ 2015; 351.
4. Nicholson PJ. Occupational health: the value proposition. Society of Occupational Medicine. London. 2017. https://www.som.org.uk/new-report-reveals-value-occupational-health-uk-b...
5. Faculty of Occupational Medicine. Annual Report 2006. Faculty of Occupational Medicine. London. 2006. http://www.fom.ac.uk/wp-content/uploads/2006-annual-report.pdf
6. Faculty of Occupational Medicine. Annual Report 2014. Faculty of Occupational Medicine. London. 2006. http://www.fom.ac.uk/wp-content/uploads/2014-annual-report.pdf
7. Nicholson PJ. Occupational health services in the UK — challenges and opportunities. Occup Med. 2004;54:147–152.
Competing interests: No competing interests