Article explaining the impact of the implementation of the new FOM regulations

1. The new standards for occupational health in the UK - Feature
Article
Lucy Kenyon investigates how the new accreditation system for occupational health
standards in the UK could work, looks at potential pitfalls and what occupational
health service providers need to do now.
Introduction
In 2008, the Select Committee on Work and Pensions published a Third Special Report, which
identified “potential for the Health and Safety Executive (HSE) to build on its Stress
Management Standards as a tool to demonstrate what a ‘good’, healthy workplace should be,
including what constitutes a good occupational health structure within an organisation”.
Occupational health (OH) providers were previously encouraged to “embrace the opportunities
and mutual benefit of self-governance and regulation of quality within both occupational health
and well-being services”, in the expectation that this would raise awareness of the professional
OH services available to employers and deliver opportunities to promote our profile within the
research community.
The new performance standards published by the Faculty of Occupational Medicine (FOM) give
OH providers the opportunity to assess and benchmark themselves and join an accreditation
scheme equivalent to a quality mark. The standards set six categories.
1. Business probity.
2. Information governance.
3. People.
4. Facilities and equipment.
5. Relationships with purchasers.
6. Relationships with workers.
Having issued the standards, the FOM is now developing an accreditation system to be piloted
later in 2010 and operational in early 2011. In order to explore what accreditation might look
like, it is useful to take a look at existing professional accreditation systems in detail.
The World Health Organization advocates for sustainable external quality assessment
programmes and it is necessary to:
• identify national training and resource needs
• allow the development of national and global advocacy tools for excellence
• identify deficiencies in procedures, practices and materials
• encourage the use of standardised procedures, practices and materials.
A review of accreditation systems for health service delivery recommended that a robust
process should constitute “an external review of quality” with four principal components.
1. To be based on written and published standards.
2. To be peer reviewed.

2. 3. To be administered by an independent body.
4. The accreditation should encourage organisational development.
Written and published standards
The FOM has now published standards for core clinical occupational health services. These do
not apply to non-clinical services, eg occupational hygiene and ergonomics. OH services seeking
accreditation will need to ensure that professional advisory services are supported by suitably
qualified or registered individuals.
The standards represent minimum standards of professional activities. No OH service will be
accredited if it fails to meet all applicable statutory requirements.
Pre-qualification questionnaire
OH services seeking accreditation will have to attest to meeting eligibility criteria for
accreditation, providing true and contemporaneous and not misleading information, complying
with all applicable laws and regulations and having appropriate insurances. The attestation will
have to be signed or co-signed by at least one registered health professional from the OH
service.
It is not clear from the publication whether health professionals have been petitioned about the
requirement to sign the attestation, nor whether they believe they have the necessary skills,
knowledge or competence to attest about, eg business probity.
Many smaller providers seeking accreditation will lack the resources to carry out a review of
third parties carrying out assessments at small satellite or remote locations of customers and
will shy away from recommending fellow providers.
Customer satisfaction surveys
OH services seeking accreditation or re-accreditation will have to provide a list of customers and
key contacts from which a sample will be approached to complete and return a customer
satisfaction survey answering pre-determined questions. Small service providers which have
just one client should engage with the client to ensure that there is mutual understanding of the
systems and processes required for accreditation.
Web-based assessment
This will allow evidence to be submitted online to determine the readiness of the OH service for
an on-site assessment visit.
On-site assessment visit
An external audit will be undertaken by a visit to the OH service. It is not clear what this will
look like where the service is delivered on-site for the client with minimal records held at the
registered address. Small service providers which involve themselves early in the development
of accreditation will have the opportunity to ensure that the external audit assessment
embraces the full range of providers in the marketplace.
Self assessment
OH services seeking accreditation or re-accreditation will have to undertake self-assessments in
years when an external audit is not performed. Professional OH staff will be familiar with self
assessment and portfolio evidence, and businesses employing OH professionals should call on
these skills when considering applying for accreditation. This could operate in a similar way to
the online self assessment operated by schools.
Review by professional peers
The stakeholder group involved in the development of the standards includes a number of

3. nursing professionals and representatives of their professional bodies. OH providers offering
nurse-led services should consult their representatives about how external accreditation will be
administered by their peers.
Encouraging organisational development
The standards clearly state that accreditation is not an end point. It is intended to drive
continuous improvement, allowing OH services to self-assess their services and performance
against standards, identify improvement areas and take remedial actions.
Other accreditation services have shown that organisations that use them can spot potential
weaknesses in their programmes or services and work proactively to prevent these becoming a
problem.
Impact assessment
Lord Darzi’s 2008 report, High Quality Care for All: NHS Next Stage Review and a Google search
for accreditation systems monitoring services similar to OH, generated a limited number of
results. One such service is the International Accreditation Society, which aims to provide
assurances that agreed standards for training and assessment are being met through an
independent monitoring and review service for those wishing to develop a world class
management style.
In its response to Dame Carol Black’s report, the Institution of Engineering and Technology
refers to a shortage of OH professionals. This remains unresolved today, and it is hard to see
how an accreditation system, which appears heavy on paper evidence, is going to encourage
more practitioners into the field. The report also talks about the barriers facing employers when
trying to implement complex and expensive solutions. In the longer term, accreditation will
need to encompass the softer evidence for “value for money” and ease of implementation, as
this is likely to be a key driver for employers.
On face value, the process appears to require evidence of process rather than evidence of
robust practice. An example would be the recruitment of professionals. Is a standard interview
questionnaire as good as notes from an interview recording the answers given by an exceptional
candidate? But of course, how many candidates would want the interview notes published? Will
this improve or hinder the number of people coming into the profession?
Quality systems are great when it comes to ensuring that widgets are all sized within tolerances
— none of us want to fly on a plane whose engine parts are out of balance — or that there is a
minimum rather than average number of screws in a self-build wardrobe. But how realistic is it
to focus resources on a system rather than professional opinion and judgment? Who is the
accreditation there to help? The companies asking for ethical and professional advice? Or the
insurance companies seeking to challenge employer liability claims?
Business probity
The author believes that, managed in the right way, the new accreditation has the potential to
change the way OH services are marketed and sold, and to level the playing field between large
established providers with the resources to invest in their products and new entrants to the
market. This is very important where there is a shortage of OH services and competent OH
professionals. This could encourage OH professionals, who have transferred their skills
elsewhere in the professional services market, back into the field of OH.
The most important factor of the new standards is probably the opportunity to demonstrate the
integrity with which OH services are offered and developed. Many larger organisations now offer
off-the-shelf packages, marketed and sold by sales professionals rather than OH professionals.
The risk of this strategy is that the services sold to an organisation do not match their needs in
terms of outcome. Employers need to be sure that their needs have been understood and that
the product is going to add value. An example of this is a sickness absence service that
operates on the basis of a single assessment with the individual. If the individual’s recovery is
atypical or a return to work is not straightforward, the employer does not have access to any
follow up unless it buys another single assessment or a different product.

4. The Department of Health business probity audit processes include:
• the adequacy of financial systems
• the appropriateness of arrangements for the prevention and detection of loss arising from
fraud or corruption
• the adequacy of arrangements for establishing the legality of proposed actions
• the accuracy of the annual accounts.
OH business probity will be assessed via a customer questionnaire. This is an area where NHS
plus services may be at an advantage. Small and independent sector providers should start to
consider and document their corporate and social responsibility policies and procedures and how
this influences their service offering and pricing strategy.
Information governance
Over recent years, the Information Commissioner’s Office has developed strict codes around the
management of information. This is supported by the guidance provided by the professional
bodies that govern medicine and nursing. Providers will need to develop a policy statement and
procedure to demonstrate how they comply with the various codes of practice, to support the
attestation and for submission to the web-based assessment.
The provision of meaningful data from confidential services is an ongoing issue for OH
providers. There continues to be a gap between the reports required by employers and those
possible from data management systems. Review reports generated through the new
accreditation service should help providers to identify and acknowledge the weaknesses in their
data management systems, and understand the need to revisit the recording and reporting of
qualitative information.
People
Competence has been a hot topic for some time now, especially with the advent of new
professional roles allied to OH, eg case managers and OH technicians. There are some legacy
issues surrounding the competence of both registered and unregistered professionals delivering
OH services that will need to be addressed. There is an opportunity here for accreditation to
influence the professional registration bodies.
Facilities and equipment
The calibration of equipment is essential to the safe delivery of, in particular, health surveillance
services. However, this can be mitigated by the use of appropriate validated questionnaire tools
with onward referral for specialist assessment by symptom profile. OH professionals are often
required to deliver professional services on site in locations that do not allow for privacy and
discourage full disclosure of symptoms by workers.
When accreditation has become established, there is another opportunity here for accreditation
to influence employers through their professional or industrial bodies to take these issues more
seriously.
Relationships with purchasers
This links back to the principles discussed in business probity. Services offered from a
foundation of ethical principles are more likely to be credible and compelling for employers. OH
providers should be able to use the evidence portfolio for this standard as a toolkit to plan
services with a new customer.
Relationships with workers
This is probably the most complex area of OH practice. This is especially true where employers
are introducing OH for the first time and have not consulted sufficiently with staff.

5. OH services should operate as exemplary employers and therefore have the strategies and
information to assist their clients where relationships with workers become a problem. Clearly,
there are some very sensitive issues here and the FOM stakeholder groups should be able to act
as advocates on this issue.
Discussion
Voluntary accreditation systems are considered to be more effective than mandatory
programmes, as they are seen as an acknowledgement of reality, and tend to set sights higher
than the minimum. They are most effective when they combine both evaluation and supportive
consultation, which means that the accrediting reviewer must hold professional credibility to
advise and recommend change. The FOM of the Royal College of Physicians is an authoritative
body for consultation in matters of education and public interest concerning occupational
medicine.
Since the early 1980s, the Association of MBAs (AMBA) has developed an accreditation service,
which it believes gives business schools international credibility and status. It helps students to
select a meticulously tested programme and employers to recruit staff who have succeeded in
that programme. The AMBA accreditation process is designed to help business schools spot
potential shortcomings in their programmes through a consultative report following the
assessment, which outlines recommendations for improving provision in the future.
When FOM accreditation is implemented, it should include as standard a recommendations
report following each self and on-site assessment. It should also provide a helpline to support
both employers and OH providers seeking accreditation and trying to overcome issues
highlighted by the process.
Conclusion
Employers will need advice and help to ensure that their OH services are appropriate, suitable
and competent. What is not certain is whether the current standards address employers’ key
concerns when procuring OH services. This is particularly true with respect to the standards for
business probity and people.
OH services wishing to prepare for accreditation need to start to collect and collate evidence in
a portfolio. Providers who do use valued and competent but unregistered professionals will need
to ensure that their performance management frameworks are included in this portfolio. This
may create some unease about sharing confidential and commercially sensitive information in a
highly competitive market.
As accreditation is not becoming available till 2011, employers interested in achieving
accreditation should engage with the FOM to participate in any pilot or trial exercises. This will
offer the opportunity to influence the accreditation process to make it more user-friendly and
also enable them to achieve accreditation at the earliest opportunity.
Further information
• Occupational Health Service: Standards for Accreditation, FOM, January 2010
Last updated on 19/05/2010
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