Setting up an occupational health service to support the military can pose a number of difficult challenges. Carolynne Davey discusses how she approached the task.
In March 2006, Carolynne Davey was appointed to set up an occupational health service as the first OH adviser (OHA) for Soldiers, Sailors, Airmen and Families Association (SSAFA) Forces Help.
Founded in 1885, SSAFA Forces Help is a charity that helps and supports British armed service personnel, ex-service personnel and their families. The OHA post was to be a sole charge position attached to the HR department, while the OH service was to be based in Germany, where approximately half of SSAFA Forces Help staff are located.
In setting up a new service, you need to consider a number of issues: the workforce and their roles; the processes and products; the locations and workplaces; and the resources available to the service. The SSAFA Forces Help workforce consists of 700 professionally trained staff, including healthcare and social work staff - working anywhere in the world that the British forces are based, including the UK, Germany, Cyprus, Gibraltar, Nepal, Brunei and Batus (Canada). They are not sent to war zones. Staff at overseas bases work on military camps based in military medical centres, military hospitals or office premises. Some staff are based at home and there are many lone workers, both in the UK and overseas. There are also 6,500 SSAFA branch volunteers.
Pre-employment health assessment process
One of the first tasks was to review the existing pre-employment health assessment process. There were two main considerations: one was to put in place evidence-based practice (Hargreaves, 2006; Ackroyd, 2006; Kloss D, 2006; Data Protection Code, 2005); the other was compliance with the Ministry of Defence (MoD) health requirements for sending employees and dependants on overseas postings.
SSAFA Forces Help subscribes to the MoD for healthcare provision overseas so it was logical to adapt the MoD pre-employment health questionnaire and family health declaration form. If healthcare needs are not met it can end in repatriation as well as disruption of services. After a series of modifications and reviews, two health assessment forms for pre-employment were produced. The first, briefer form is for people who are based at one location and focuses on three key questions (Hargreaves, 2006). The second is for those recruited for overseas postings and this is aligned to the MoD assessment.
If healthcare needs are not met it can end in repatriation as well as disruption of services."
Davey produced a written procedure for the pre-employment health assessment with 18 supporting documents and forms.
The first document was called "Forms for Jobs" and was intended to be a simple guide to assist the HR team when selecting the right forms and information sheets to send to the successful candidates when a job offer was being made. A reply envelope addressed to the OH adviser and marked "confidential" is sent by human resources to the successful candidates along with the forms.
The procedure also includes health assessments for staff who transfer to different geographical locations as requirements can be more stringent where secondary care facilities are limited and not to the standard that exists in the UK, for example, in Brunei and Nepal.
Health assessments for those who change to a different type of job are also included in the procedure, for example, a change from administration to primary care assistant. This is to ensure that any risks can be managed, immunisation status can be checked if relevant and reasonable adjustments can be made if required. A leaflet introducing the OH service is sent out to successful applicants along with the OH and HR forms.
Prior to the launch of the Equality Act 2010, the procedure was reviewed and updated. Under the new Act, health enquiries cannot be made prior to a job offer unless a legal exception applies, for example a standard of health/ability is essential for the role.
Minor changes were required, for example, references to the Disability Discrimination Act 1995 (now repealed) were changed to the Equality Act 2010 on the forms.
This review also provided the opportunity to see if any amendments were required in relation to the report on pre-employment health screening of NHS staff (Madan and Williams, 2005). No further changes were made.
Vaccination and immunity
SSAFA provides a wide range of healthcare staff, including primary care nurses, primary care assistants, midwives, health visitors, children's nurses, sexual health nurses, community psychiatric nurses, pharmacists, dispensary staff, speech and language therapists, emergency care practitioners and doctors, who are based at medical centres in the UK as well as overseas.
In accordance with the Control of Substances Hazardous to Health Regulations 2002, employees who may be exposed to biological or chemical hazards require protection. As part of the pre-employment assessment, the successful candidates must have their vaccination and immunity status established and immunisation offered if it is required.
Two forms were produced for this purpose. One form was for clinical healthcare workers (for example, all categories of nurses, doctors and midwives) and one for non-clinical workers who do not have "hands on" contact with patients (for example, pharmacy staff and administration staff).
Chapter 12 of the Green Book and Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: new healthcare workers were used as references for these forms.
Staff or candidates who are being posted to locations such as Brunei and Nepal are also advised about vaccinations required. The MoD guidance is followed for this.
Policy and procedure
In addition to the pre-employment health assessment procedure, a decision was made to produce a hepatitis B immunisation policy. The purpose was to assist in assuring that all clinical healthcare workers were immunised. It also served to support the military medical centres in maintaining their hepatitis B vaccination registers.
Sickness absence management and rehabilitation was another area where it was felt that policy and procedure were required."
The policy included a report to the "designated person" for each unit and a "hepatitis B immunity status notification" is issued for each clinical healthcare worker. The military medical centre registers are required and inspected as part of their accreditation audits.
Sickness absence management and rehabilitation was another area where it was felt that policy and procedure were required, so a rehabilitation policy was produced.
In 2009, when the National Institute for Health and Clinical Excellence (NICE) produced its guidance on rehabilitation, it was found that when the policy was reviewed it did not need to be amended or updated. A referral form was designed for managers or HR to use to refer employees to OH. The form has tick boxes to guide staff on what to ask for from a referral. This assists in focusing the referral to answer specific questions and to facilitate a planned return to work.
To accompany the referral to occupational health, consent forms were produced, for referral to the OHA, for obtaining GP reports and also for referral to an OH physician (OHP), should this be required.
The request for a GP report consent form was designed as a two-page form. One page is an information page for the employee to keep, which informs them of their rights under the Access to Medical Reports Act 1988, while the second is the consent form.
The consent forms for referral to OH or an OHP inform the client that they will receive a copy of the report that is sent by OH to management or HR.
Clients are referred to OH by their managers or HR, they can self refer, or OH may be aware of an individual with a health concern and contact them directly to offer support. Most consultations are by phone.
The OHA role is semi-peripatetic. Logistically it is not always possible to visit clients for face-to-face consultations. If a case conference is required when there has been a long-term illness or significant health condition, this will be a face-to-face meeting with the individual, their manager and possibly other relevant personnel (for example, a healthcare provider). Contact between meetings is via telephone consultation.
The OH adviser is located in the "central region" of British Forces Germany and visits the UK every one to two months, including visits to Royal Air Force bases.
Visits to the other SSAFA overseas locations such as Gibraltar and Cyprus take place periodically for activities such as staff training, for example, health and safety and stress management.
OH provides health and safety support for adventure holidays organised by SSAFA for the military communities' disabled children, siblings of disabled children and carers. OH carried out risk assessment of aspects not covered by the holiday parks themselves using the Health and Safety Executive (HSE) template from "Five steps to risk assessment". Photographs of equipment were used as part of the volunteer training, while a questionnaire is used for volunteers involved in activities such as climbing, horse riding and swimming.
Even with many years of OH experience there is always a variety of new activities to become involved with. In Germany, the OH adviser suggested ergonomic setups at the military medical centre pharmacies. This involved visiting the pharmacies, speaking with staff and conducting assessments using three relevant papers (Alexander, 2004; Michael, 2000; May, 1997).
One (Alexander, 2004) appeared to have a number of the ergonomic similarities to the pharmacies that were being assessed. There had been a small number of cases where employees with pre-existing musculoskeletal problems had experienced discomfort. Much of this was related to working at bench height. Pharmacy staff vary in height and the workbench surfaces are not adjustable. Finding an optimal height that all staff were comfortable with proved to be challenging; the solution was based on research on heights for light assembly (85cm to 90cm for females and 90cm to 95cm for males) and precision work (95cm to 105cm for females and 100cm to 110cm for males) (Kroemer and Grandjean, 1997).
There have been both challenges and rewards in setting up the SSAFA Forces Help OH service."
Staff appeared to be happy with a height that was within these two ranges, 1m, and this might have been because, although filling prescriptions might be likened ergonomically to assembly work, handwriting tasks are required fairly frequently and this is more precise work. As a result of the assessments, a number of low-cost adjustments were made and feedback from staff was positive.
The OH adviser also gave input for the out-of-hours telephone assessment service in Germany, which works in a similar way to NHS Direct. The service operates between 8pm and 8am, 365 days a year. It was staffed by two primary care nurses and one primary care assistant and based in an office in a medical facility. Local Authority Circular 94/2 on health and safety in call centres provided useful information for selection of equipment and giving advice on environmental conditions.
As part of the SSAFA's expansion during the last three years, the association has begun managing primary care health centres on behalf of primary care trusts. There are currently two in operation and a third centre is being built.
There is also an emergency care practitioner service. This part of the OH service differs from that related to staff who work in military medical centres as policy and procedure for the latter such as infection control and health and safety come under the remit of the military. The SSAFA OH service provides support for these satellite UK services with activities such as policy, procedure and health and safety induction training.
While part of the new business area is expanding, in the future other parts will be reduced. As British Forces Germany closes down locations such as Joint Headquarters Rheindahlen, support services such as healthcare and social work will be reduced. Supporting staff emotionally and psychologically through times of change may be required.
There have been both challenges and rewards in setting up the SSAFA Forces Help OH service, including settling into a military community and in a country where the OH adviser is not fluent in the language. This helps develop empathy, particularly for new arrivals at the overseas locations.
The OH adviser has also been fortunate in that managers have supported her professional development and encouraged study, through attendance at conferences and courses both in Germany and in the UK.
The opportunities to provide support for the children's holidays and to travel and see staff in their work locations such as Gibraltar and Cyprus have been interesting and worthwhile.
Carolynne Davey is occupational health adviser for SSAFA HR.
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XpertHR provides further information on setting occupational health standards.