Research and analysis

Summary: Understanding the provision of occupational health and work-related musculoskeletal services

Published 28 May 2020

1.1 Overview

This report presents the findings from research commissioned by the Work and Health Unit (WHU), to map the current provision of occupational health (OH) in the UK^{[footnote 1]} and review work-related musculoskeletal (MSK) services in the NHS.

The research aimed to examine the available models of private and NHS service provision; how these are commissioned, resourced and accessed; examine the workforce of private and NHS providers; and investigate the commissioning of MSK and work-related NHS services. The research is intended to inform the ongoing development of policy relating to OH.

The definition of OH used throughout this research is: advisory and support services which help to maintain and promote employee health and wellbeing. OH services support organisations to achieve these goals by providing direct support and advice to employees and managers, as well as support at the organisational level, for example to improve work environments and cultures.

1.2 Research context

The Work and Health Unit (WHU) is a UK government unit which brings together officials from the Department for Work and Pensions (DWP) and the Department of Health and Social Care (DHSC) to lead the government’s strategy supporting working age disabled people, and people with long term health conditions enter, and stay in, employment. To enable this, the government aims for more individuals to have access to appropriate and timely OH advice.

As set out in the WHU’s consultation, ‘Health is everyone’s business: proposals to reduce ill-health related job loss’^{[footnote 2]}, the government recognises that action is required to ensure employers are able to purchase good quality, cost-effective OH services that meet their needs. Complementary improvements will be needed to ensure the OH market has the capacity to respond to greater demand, and is able to deliver these services to employers of all sizes.

1.3 Methodology

The research is comprised of 5 main components, designed to capture a range of perspectives on OH and MSK provision:

• in-depth interviews with 8 experts in the fields of OH and/or MSK, and a literature review
• a semi-structured telephone survey of 103 OH providers (representing 32% of the sample built of private OH providers)
• a further semi-structured telephone survey of 156 private and NHS providers that sell OH services commercially (representing 36% of the sample built of private and NHS OH providers)
• a semi-structured telephone and online survey of 111 Clinical Commissioning Groups (CCGs, representing 58% of CCGs)
• 15 in-depth qualitative case studies with OH providers and employers that have used their services

1.4 Main findings

1.4.1 Scoping out the history of OH and MSK provision: Chapter 3

When the NHS was established, OH was not included in its responsibilities, but responsibility fell to the employer instead. In the experts’ view, the NHS’s traditional stance has contributed to employment outcomes being largely overlooked in studies of health interventions and a lack of leadership in OH, resulting in fragmented OH provision.

Experts reported that provision of OH has gradually shifted from an in-house function to an outsourced model, mainly due to employers seeking to reduce costs. However, they felt the training of OH professionals has not been taken up by out-sourced private providers to the same extent, and as a result the pool of UK OH expertise is perceived to be dwindling.

Weaknesses of OH provision identified by experts included uneven access to OH and work-related MSK services, a missing link between treating health problems and supporting individuals to work and OH not having been prioritised sufficiently by employers. Experts felt that key elements that contribute to effective provision include awareness that good quality work can lead to improvements in employee health and wellbeing, employers and managers with strong understanding of and belief in OH, multidisciplinary care and stratifying patients by severity of condition. The experts, and the evidence from literature, pointed towards some key models used in current delivery of OH and work-related MSK provision. These tended to fall within the domain of the employer, or the individual and their GP.

In the employer domain, Employee Assistance Programmes were felt by experts to be a relatively common pathway for referring employees to OH specialists. Also thought to be relatively common was employer-funded ‘basic’ OH provision to meet legal requirements, such as health surveillance. By comparison, a bespoke OH and MSK offer that is fully-tailored to the employer’s workforce, was felt to be comparatively rare.

1.4.2 Private providers’ OH offer: Chapter 4

OH providers offered a broad range of services. They placed considerable importance on tailoring of services to meet employers’ specific needs, even when services were delivered through ‘off the shelf’ packages. Two services stood out as the most commonly commissioned; health surveillance (33%) and assessment of fitness for work (24%).

A substantial proportion of private OH providers had relatively small-scale capacity. Four in ten (39%) had capacity to support fewer than 200 individuals at any one-time. Demand did not appear to be exceeding supply, as of the available private OH market capacity amongst those who participated in the research, 89% had been taken up over the last 12 months.

Employers were the main commissioners of OH services: almost all providers (97%) had been commissioned by employers. Around half (54%) of OH providers had been commissioned by individuals, often self-employed individuals or those looking for work seeking mandatory medicals.

Line managers and other employer representatives were frequently involved in assessments of fitness for work and workplace adjustments, but their involvement was often limited to the start and end of the process. OH providers noted the importance of involving the line manager in the process, and this was most successful when line managers had a good understanding of OH.

Nearly all OH providers (96%) said their OH support interacted with NHS provision, most commonly recommending employees go to their GP or specialist treatment.

Seven out of ten (69%) OH providers captured data on the outcomes achieved through their support in all or most cases, with 56% capturing it in all or nearly all cases. Providers that did so felt it allowed them to establish trends and identify ways to improve their service. Virtually all (99%) OH providers used some form of training, development or accreditation system, and the majority of these providers (96%) felt these were effective in ensuring quality of service.

Six in ten OH providers (63%) did some form of marketing, mostly directed at employers (97%). Those who did no marketing (37%) did so because they felt they received enough business without it.

1.4.3 OH provider workforce: Chapter 5

Most private OH providers had only a small number of employees (17% were sole traders and 43% had 1 to 9 employees). The majority of private OH providers (82%) subcontracted to additional members of staff on a regular ongoing basis.

On average, two-thirds (64%) of staff employed or subcontracted by private OH providers were medical professionals (such as doctors or nurses), and the most commonly employed role was registered nurses with a SCPHN OH qualification^{[footnote 3]} followed by occupational health physicians (OHP). Eight out of ten private providers (78%) felt they had the right balance of medical and non-medical staff. The more specialised and bespoke job functions were reserved for medical professionals with specialisms or qualifications, while less specialised staff spent more time delivering services that were more process-driven.

Three-quarters (76%) of private and NHS OH providers had access to funding for staff training. Amongst those with access to funding, the organisation themselves partly or wholly funding a course was the main source (61%). A third (35%) of providers funded training posts, although on average there were more training posts available than had been filled.

The majority of private and NHS OH providers (67%) had recruited new staff in the previous 12 months, most commonly registered nurses with a SCPHN OH qualification (37%). Just over a third (37%) reported having at least one vacancy (again most commonly for registered nurses with an SCPHN OH qualification (24%). Just under half (44%) of private OH providers had roles that they were unable to fill, most commonly OH nurse or physician roles. They felt that this was due to a decrease in medical professionals with OH experience in recent years. Specifically, registered nurses with a SCPHN OH qualification (51%), nurses with other OH qualifications (41%) and occupational health physicians (37%) were seen to be the most difficult roles to recruit for.

The most common course of action to take when a role could not be filled was to maximise the capacity of the current workforce, with 7 in 10 (72%) restructuring teams and workloads and two-thirds (63%) training and promoting existing staff. However, half reported that they had been forced to turn down work (53%) and/or manage the services they were able to provide (49%), for instance by limiting client numbers. While on the face of it this may conflict with the finding that most private OH providers are not operating at full capacity, it is plausible that providers may be (i) turning down work that would see them operating at or above full capacity due to recruitment difficulties; or (ii) managing the services they provide so as to avoid approaching full capacity.

1.4.4 Clinical Commissioning Group (CCG) commissioning of musculoskeletal services: Chapter 6

Nearly all CCGs commissioned MSK physiotherapy (99%), podiatry (97%), injection therapy (96%), joint replacement (95%) and specialist pain clinics (91%). MSK physiotherapy was the most commonly used community-based MSK service among working age people: 88% of CCGs reported that it was in their top 3 most commonly-used community services. Specialist pain clinics were the most commonly used hospital-based MSK service among working age people (71%).

MSK care for working age people was widely considered a priority area by MSK leads in CCGs, with a quarter (23%) viewing it as a very high priority and half (50%) as a high priority. Common reasons for this included the strategic redesign of MSK services, this being a known NHS priority or the CCG feeling they were not doing enough – all of which may imply a relatively recent shift towards prioritising MSK services for working age people. Responsiveness to demand was also a factor, with 17% reporting that it is a priority because it is the most-accessed service.

Tailoring of MSK services to the health needs of the working age population was widespread among CCGs (91% tailoring to at least some extent; 70% tailoring ‘mostly’ or ‘completely’ to these needs). However, this was mostly limited to flexibility in access, such as flexible appointment times (46% of CCGs that tailor their services) or locations (22% of these CCGs). Responsiveness to demand recurs as a theme; tailoring was most commonly driven by perceived needs of the local population or public consultation. Tailoring the services themselves to the needs of the working population was less common, as was tailoring being driven by best practice or expertise.

The majority of CCGs (79%) reported that none of their services were commissioned specifically with employment needs or vocational rehabilitation in mind. MSK physiotherapy and specialist pain clinics were the services most commonly cited as being commissioned on this basis (by 15% and 11% respectively), typically because these services were known to have a better chance of getting people back to work.

Working age patients were most commonly referred via their GP to both community and hospital-based MSK services. Self-referral was also relatively common, particularly for community-based MSK physiotherapy.

The vast majority of CCGs (93%) reported at least some deliberate commissioning of MSK services with the intention of facilitating patient access to multidisciplinary support^{[footnote 4]}. However, these multidisciplinary services were not commonly focused on employment needs or vocational rehabilitation. Where these multidisciplinary services were commissioned with a focus on employment needs or vocational rehabilitation, most commonly, this was because multidisciplinary MSK services were thought to be effective in ensuring the best possible course of treatment.

Four-fifths (79%) of CCG MSK leads agreed that MSK services meet the needs of local working age people, but only 14% strongly agreed, suggesting some scope for improvement. When asked what elements of MSK commissioning are currently working well, efficiency was a recurring theme whereas managing patient demand was seen as a key area for improvement.

1. Research with NHS bodies was limited to England only ↩

2. Health is everyone’s business, July 2019, DWP and DHSC ↩

3. Those registered under part 3 of the NMC register, the highest OH qualification a nurse can achieve. ↩

4. This was defined as support from 2 or more members of staff from different disciplines, whether clinical or not. ↩