Three studies of OH provision for NHS staff paint a variable picture of the development of the service since the late 1990s:
1998
99.6% of trusts claimed to provide access to OH in 1998, but virtually no service was provided to primary care staff. There was also wide variability in the quality and range of OH available, and only a third of employers had access to a specialist occupational physician. There was substantial inequality of access to OH services and the NHS had not met its 1994 target of providing access to specialist OH services to all staff (Hughes et al, 1999):
■ 70% of trust employees in the late 1990s had access to a service based with their employer; 27% were provided with OH from another trust; and 3% from the private sector. It was clear that provision of an OH service from within the NHS was, and is, the preferred option for NHS employers;
■ Only 38% of OH departments in 1998 employed a doctor full time and almost two-thirds employed one for half time or less. It was estimate that only 27% of the total NHS workforce received specialist medical OH services;
■ at least half of in-house OH departments employed three or fewer nurses; 61% of these nurses held a recognised OH qualification and a further 15% were in OH training positions. More than two-thirds (69%) of departments had at least one nurse with a degree in OH or an OH nursing diploma. More than two-thirds (69%) of nurses worked full time and 96% of departments had at least one full-time nurse;
■ the number of potential clients per OH nurse varied, but not as widely as the doctors’ lists, with an average of 1,838 clients per nurse. There was no suggestion in 1998 that inadequate doctor cover was supplemented by additional nurse cover; and
■ OH in primary care was virtually non-existent: 79 out of 90 health authorities had no formal arrangements to provide OH services to GPs or their staff.
2001
The amount of doctor time available for the occupational health of NHS employees increased between 1998 and 2001, as did the proportion of doctors holding professionals qualifications (Hughes et al, 2002). However, big variations in service levels continued to exist and government policy that all NHS staff should have access to a consultant led service had not yet been implemented. However, more doctors were working more sessions for their trusts and were better qualified in OH and many also undertook the OH function in settings other than their NHS trust environment. No real rise in the number of doctors in training in the specialty took place between 1998 and 2001. It is also possible that an increase in the medical staffing in NHS OH services may not have been matched by improvements in other crucial OH staffing provision, for
140
■ the number of consultant staff rose by 50% between 1998 and 2001, and there was a small increase in the proportion of specialist registrar grades in OH;
■ the proportion of doctors holding an FOM qualification rose to 60%;
■ the proportion of doctors working in OH departments without an OH qualification fell from 33% to 22%; and
■ there was a 50% rise in the number of full-time doctor posts and a rise in the number of sessions worked by doctors in OH departments amongst the remainder between 1998 and 2001.
2002/03
All NHS trusts provided some OH but this was largely reactive and the quality and accessibility varied (National Audit Office, 2003). The number of trusts signing up to NHS Plus had levelled off and some noted that the resources generated by this scheme to sell OH services to non-trust employers were not being invested in improving the provision of services:
■ all trusts provided OH in 2002/03, but this was usually only available during normal office hours, and only 50% had arrangements for staff who required out-of-hours cover;
■ 82% of acute trusts had dedicated in-house staff, compared with only 30% of mental health trusts and 17% of ambulance trusts. Of the rest, 35% contracted OH from another trust; 3% from a non-NHS provider; and 5% used a combination of provision;
■ constraints on provision included difficulties recruiting suitable staff (just under half cited this as a barrier); lack of resources for investing in OH (72% of ambulance trusts; 41% of acute trusts); and problems with accommodation/geographic location (around a third of all trusts cited this as a barrier);
■ staffing varies widely;
■ sickness absence in trusts falls as OH spending per employee increases (but this finding is based on only 13% of trusts);
■ the services provided are largely reactive (for example, rehabilitation and post exposure screening) rather than proactive (for example, health surveillance, promotion and education). Part of the reason for the reactive nature of OH in the NHS is that the allocation of resources is dictated by legal requirement to provide OH checks on staff, especially when they move to another trust. This means fewer resources are available for proactive services; and
■ 68% provided fast track treatment programmes for particular conditions (for example, physiotherapy for MSDs).
Access to OH in primary care
Practice managers in primary care identify some improvement in OH provision in recent years (Reetoo et al, 2004). However, awareness of the available provision is variable and some managers regard their services to be understaffed and difficult to access due to location. Practice nurses also feel that provision has improved, citing protocols for needlestick injuries, and checking of immunisations. Knowledge of available OH provision amongst GPs was quite limited. Mental health problems were the greatest concern for this group, and GPs would like to see quick access to services where concerns over confidentiality are minimised.