NHS occupational health working hard to show its value at board level

Recruitment and retention, workload, rundown working environments, poor data, and community health inequalities remain key challenges for NHS occupational health teams, a conference heard last week. Yet perhaps the biggest is simply answering the question, “and what value do you bring?”, as Nic Paton reports.

NHS in-house occupational health services face serial challenges around recruitment and retention, workload, joining up data and their ability to influence change on the ground within their communities and more widely – but perhaps the main one remains showing the value they can bring at executive and board level.

These were some of the key messages outlined by Kelly McClenaghan, head of the employee wellbeing service at Barts Health NHS Trust, at last week’s joint Royal College of Nursing/SOM (Society of Occupational Medicine) occupational health nursing conference.

On the plus side, however, in-house teams can often bring rich local intelligence to the delivery of OH services, she emphasised. They may as a result be able better to recognise and respond to community health inequalities.

Through cross-trust collaboration and knowledge-sharing, in-house teams are often in a position to develop powerful multidisciplinary approaches, McClenaghan also pointed out..

Post-pandemic profile

McClenaghan highlighted how the pandemic had significantly helped to raise the profile of occupational health within the service, something reported by OHW+ at the time.

“Working through the pandemic put us back on the map in terms of occupational health. We got loads of recognition; I think it really brought it to the forefront,” she said.

However, whether this greater understanding of what occupational health does has translated into greater recognition at senior management and executive level is perhaps more moot, as McClenaghan highlighted through a telling anecdote.

“We had an exec programme a couple of months ago that I attended with the lead from the psychological service and we were promoting and talking about the work that we were doing. And the finance director turned round to me and said, ‘and what value do you add?’. I thought, ‘my goodness, we’ve got a long way to go’,” she said.

This need for the profession and practitioners to be evidencing or promoting the value of OH to organisational leaders was therefore a key strand that ran through her presentation.

Drilling down into some of the specific challenges in-house NHS OH teams are facing, budgets and finance were an ongoing headache, much as they are across the NHS.

“Sometimes we’re given what seems to be a large budget but, actually, for your resources it is really small, when you’re looking at the NHS, when you’re looking at an acute trust,” McClenaghan said, highlighting by way of example that her trust employs 20,000 people.

“And there is no standard for costs. If I’m looking at income generation, different trusts will charge different prices. Sometimes that can cause some competition. Sometimes you are also trying to compete with these larger providers that can come in at a lot lower cost. And then it is about the managers and the board. They’re still sometimes yet to realise the value, the true value, that occupational health can give. Our ultimate goal is to keep our staff well and safe so that they can give good patient care, good patient outcomes,” she added.

The physical working environment, too, can often be challenging. “For those who work in the NHS, you will probably be aware that the departments maybe need something more than a lick of paint,” said McClenaghan.

“Sometimes we’re out on a limb, we’re not integrated within the main hospital. There can be a feeling of isolation. If you work in a large trust that has several hospitals that can also be a logistical concern because things like needlesticks – you might be based in one site, you’ve then got somebody that has to travel 20-30 minutes; there is that risk that people may not attend the occupational health department if that is the case.”

Recruitment and retention

Recruitment and retention was another key challenge, compounded by the ageing demographic of the profession. “I think that most people who work in occupational health, whether it’s an NHS or outside workforce, it is absolutely one of our biggest challenges,” said McClenaghan.

“We are an older workforce, we are struggling to entice people to come into this profession, and also, with regards to occupational health physicians, we in our trust haven’t had a substantive occupational health doctor for two years now.

“So we rely on agencies, on service providers. We’re a nurse-led service anyway, but it means that the additional pressure of stepping into the shoes of the clinical lead is also another challenge.”

“I think pre-pandemic, before people started to work remotely, your occupational health nurses, your occupational health doctors, were very much doing hands-on [work]; they would be in, they would be doing the health surveillance, they might be doing the on-call duty, needlesticks, as well as case management. I think one of our biggest challenges is that people predominantly now are doing case management. So some people are losing their skills when we talk about the full remit of occupational health,” she added.

Pay and conditions and, alongside that, the lure of going over to the private sector, was a further challenge. “That’s a big issue for some people. We’ve got the cost-of-living crisis; for some people they can get more working for a provider. We’ve looked at liaising with our education academy and trying to get occupational health integrated as part of the nursing curriculum. So, [we are] trying to go along to do some talks and we’re just in the process of looking at how we can accommodate some students coming into the workplace. I am really excited about that,” said McClenaghan.

With many employees – and many team members – living as well as working within the community they serve, managing, recognising and responding to community health inequalities was a further ongoing challenge, she highlighted. These included, for example, high percentages of staff from overseas, domestic violence, poor vaccination rates and poor compliance with treatment plans.

Joining up data

Good-quality and joined-up data have been an ongoing challenge for both the NHS and NHS OH for several years, McClenaghan outlined, especially the challenge of aligning data with outcome measures.

“This is one of our significant challenges. There are a few occupational health databases that we use and they don’t tend to be able to provide you with the outcome measures. So it is then looking and using your innovation to take that to the next level, to look at how can you then create a dashboard?” she said.

Audit tools were often a further issue within this. “They’re good in terms of practice, but I think we have a way to go with looking at bespoke audit that can show the outcome measures where we actually add value,” she added.

More positively, however, in-house teams can bring their own very specific benefits, McClenaghan pointed out, not least in terms of having access to a wide range of other in-house experts. “I think we all had the opportunity during the pandemic to work with professions that we may not have worked with previously.

“From my perspective, it was great working much more closely with the psychologists, with the mental health teams, with the physio teams, with the OTs, IPC [infection prevention and control]. There is definitely that need to change, to become an MDT [multi-disciplinary team],” she said.

“I think what’s invaluable, and people potentially take for granted working as an in-house, is your access to expert knowledge,” she added, citing the value of just being able to call up, say, a trust microbiologist or cardiologist.

“It’s fantastic. In an ideal world, we’d have a fast-track policy for everything, dermatology, scans – but we also have to think about the reality of the commissioning and that for every space that an NHS worker takes up, that’s one patient slot.

“But I think the access that we have sometimes as an in-house [team] we often take for granted. It gives us the ability to set up clinical pathways, it gives us the ability to have that expert knowledge,” McClenaghan said, adding that, for example, her OH team had recently devised a skincare plan for the trust, working closely with its dermatology team.

Local intelligence

Equally, the local intelligence and understanding in-house OH teams can bring to bear, especially in terms of responding to community health inequalities, can be significant.

“If you’re an in-house service provider, as opposed to an outsourced, you’re going to know your culture; you’re going to have access to the trends. That might be sickness absence, that might be with your EDI [equality, diversity and inclusion team], that might be even from a financial perspective,” McClenaghan said. “You can then use that trend analysis to try to target certain groups and certain areas.”

The Growing occupational health and wellbeing together strategy remained a key driver for change within NHS occupational health, she pointed out, and the development of health and wellbeing guardians had also been valuable in helping to influence change.

“We used to meet every couple of months and I used to produce a report that was then taken to board,” said McClenaghan of her experience at her previous trust.

“And they really were the advocate for that. So I think it is about what value we can add. We need to be heard and some trusts are doing it really well in their occupational health and wellbeing departments. They are included in the meetings, they are included in the committees. But I think that is definitely a challenge, for you to get your voice recognised sometimes,” she added.

Finally, looking to the future, McClenaghan highlighted that NHS occupational health needs to be about the whole working lives of employees and focused on prevention and “health restoration” as much as just responding to management referrals or case management.

“For occupational health, [it is about] that work-life cycle. We need to be not just about pre-employment, we need to be there from the very beginning and being a significant influencer. As I said, to create this enhanced MDT model,” McClenaghan said.

“We’re trying to identify high-risk or vulnerable staff for their yearly checks. Let’s not wait until their health is impacted so that they come through as a management referral or they go on to long-term sick

“Creating this proactive approach to reducing the causes and factors of sickness absence. How many of you have got that as part of your objectives to reduce sickness absence? It is looking at the causative factors, it is not just about giving a good, phased return with regards to a management referral.

“I think really going forward, if you haven’t already, absolutely to use access to the wellbeing guardian. They can be your voice on the board; it is about developing that working relationship with them. Then, finally, creating that meaningful data so we can show our financial executives what value we are adding to the organisation,” McClenaghan said in conclusion.