Guest blog by Dr Lara Shemtob
Dr Navdeep Nath recently asked me to speak at a regional teaching programme for specialty trainees in occupational medicine. I went into the session hoping to discuss how occupational medicine could scale its expertise through training, triage and supervision of multi-disciplinary and non-clinical colleagues. I left the session wondering whether we have enough specialist clinical capacity to support that model. These doctors will become consultants in occupational medicine, the most qualified clinical professionals in the UK specialty. They have already completed 5-6 years of medical school and years of postgraduate training. Some had completed alternative specialty training programs before moving into occupational medicine as a second specialty and even worked abroad. This is common for a room full of OH professionals!
The big challenge relates to high levels of economic inactivity due to ill health, in a system without universal access to occupational health. The fit note (issued mainly by GPs) is currently acting as a backstop for all workers but is ineffective due to issues with time in appointments, positionally of GP teams, managing patient expectations and limited work and health training for GPs. Various government-funded approaches are currently exploring how to fill this gap. Given the scale required to reach the almost 3m individuals that are economically inactive due to ill health, delivery models will need to rely on non-clinical colleagues.
How can we get clinical expertise to go further in solving economic inactivity due to ill health in the UK? Namely: training, triage, and supervision. The response from the room was sobering. There was concern around the sustainability of clinical resources to even offer these core services to uphold a non-clinical workforce, in particular:
Training numbers - Training as a consultant occupational physician takes years. These posts requires funding, and they are not expanding adequately to meet demand. Though the Portfolio/CESR route to training is available, it can be more complex to navigate (people can drop off before completing the qualification because of how challenging it can be to evidence their competencies). Meanwhile, the occupational medicine specialty training pathway has a lot of interest, with a competition ratio of around 17 applicants per seat, a ration higher than many clinical specialties. This demonstrates that the government is not investing in the future of the specialty to the extent required, despite there being a pool of doctors interested in completing the training. There are also barriers for current and prospective trainees, given completing training requires passing multiple rigorous exit exams, and potentially a salary cut depending on where in their career they come to training from.
Non specialists with a special interest in OH - GPs with DOccMed qualifications and doctors with an interest in OH can contribute to occupational health provision, but they are not substitutes for specialist-trained occupational physicians. Many doctors who develop a special interest in occupational medicine incorporate OH practice as part of a portfolio career and do not take on full time OH work. However, there are a considerable number of DOccMed doctors currently not working in OH, so there is capacity there.
Multidisciplinary clinicians in OH – Can OH-trained occupational therapists, physiotherapists and nurses available keep up with demand?
Role sustainability - A private OH market creates a retention challenge. Public-sector roles need sustainable pay, working conditions and career development opportunities if specialist expertise is to remain within publicly delivered services. The alternative is to have public services staffed by private providers.
My takeaway was that to achieve the scale necessary to solve high levels of economic inactivity in the UK, we need to double down on the core resource. This means investing in recruiting, training, and retaining specialist occupational physicians. Models based on triage, delegation, training, and supervision can make specialist expertise go further but cannot operate without core expert clinical resource. We need to scale the number of experts to be able to achieve sustainable ways of scaling their expertise!
With thanks to: Dr Simrah Farooqui and Northwest regional occupational health trainees.