NHS occupational health services: setting the standard

A national survey of occupational health service users in the NHS makes positive reading for practitioners. Dr Sian Williams dissects the findings, which have lessons for OH advisers in other industry sectors.

Feedback from patients, regardless of the setting in which occupational health practitioners see them, is an important measure of quality of care. In 2008, Lord Darzi’s review of health services in England concluded that quality and outcomes needed to be improved. In his report “High quality care for all”, Darzi defined quality in healthcare as clinical effectiveness, safety and patient ­experience. He highlighted the importance of the entire patient experience: “ensuring people are treated with compassion, dignity and respect within a clean, safe and well-managed environment”. The Health and Social Care Act 2012 continues this theme, as does the Safe Effective Quality Occupational Health Service (SEQOHS), the national OH accreditation scheme.

Eliciting feedback from patients about their experience provides useful information to OH practitioners on how they are performing and where they need to improve. This is recognised by SEQOHS where domain F covers relationships with workers, and standard F2 needs evidence of worker feedback. For doctors, there is a General Medical Council revalidation requirement to obtain formal patient feedback at least once every five years.

How to collect feedback

The recent Royal College of Physicians’ (RCP) national occupational health patient experience survey in the NHS is a good example of how to collect feedback. Results show that NHS staff receive an exemplary standard of care from their OH service. NHS staff rate their experience of attending an appointment at their OH department very highly. More than 8,000 staff completed a questionnaire and 95% believed that overall they had received an “excellent” or “very good” OH service.

The choice of questions and responses used in patient feedback surveys determines the way in which the information can be used. For instance, there is a difference between patient experience and patient satisfaction. Patient satisfaction is a report by the recipient of their feeling about the care given, and tends to relate to their overall care. Patient satisfaction surveys are not very sensitive to specific problems within the process of care. Patients may have a complex set of beliefs that cannot be embodied in terms of “satisfaction”.

Measuring quality of care

Questionnaires that ask patients to rate their care in terms of how satisfied they are tend to elicit very positive ratings, which are not sensitive to problems with the ­specific processes that affect the quality of care delivery. This makes responses difficult to act on. A more valid approach is to ask ­patients to report on whether or not certain ­pro­cesses or events occurred during a ­specific consultation. The more specific the question, the easier it is to identify where any remedial action may be needed. The Picker Institute undertook extensive qualitative research to find out which aspects of care are important to patients. Using this information, it developed standardised instruments to measure the quality of care in relation to particular domains.

For example, a patient satisfaction survey might ask:

• How satisfied were you with the wait to see the OH professional?
  Very satisfied; satisfied; a bit unsatisfied; very unsatisfied.
  
• How satisfied were you with the OH professional’s listening skills?
  Very satisfied; satisfied; a bit unsatisfied; very unsatisfied.

However, a patient experience survey might ask:

• How long did you wait to see the OH professional?
  Seen early or on time; five mins; six to 10 mins; 11 to 20 mins and so on.
  
• Did the OH professional listen to what you had to say?
  Yes, completely; yes, to some extent; not really; not at all.

National survey

In 2011, the Health and Work Development Unit (HWDU), a partnership between the Faculty of Occupational Medicine and the RCP, invited all services providing occupational health care to the NHS in England to participate in a ­national patient experience survey. The survey questionnaire was based on the ­national outpatient survey. This is one of several national ­surveys run by the Picker Institute. The survey has been through a rigorous development process, having been used and refined in the NHS over the past 10 years. Several of the domains and specific questions have been endorsed after a review of evidence for the 2012 guidance on patient experience from the National Institute for Health and Clinical Excellence. These are areas that patients themselves have identified as important when assessing the quality of their care.

The questions in the OH patient experience survey reflect those in the outpatient survey and fall into three main areas:

• the OH department – environment and organisation;
  
• seeing an OH professional; and
  
• overall impression.

The 2011 national outpatient survey was completed by more than 72,000 patients, while the 2011 OH survey was completed by nearly 8,000 NHS staff after their OH appointment. Both reports are freely available and some of the findings are shown in the tables at the end of this article.

Each participating OH service received its confidential local results benchmarked against the national average. Where a ­similar question was asked of NHS out­patients, this was also benchmarked against these results.

The OH survey results were consistently better than the national outpatient survey findings from the same year. There may be several reasons for this. OH departments tend to be smaller than hospital outpatient departments, with relatively lower patient numbers and consequently shorter waiting times. Length of consultation is often longer, giving the clinician more time to ask questions and the patient more time to answer them. OH patients attending more than once may be more likely than hospital outpatients to see the same clinician, resulting in better continuity of care.

Barriers to relationships

However, there are also some perceived barriers to the development of a good rapport between the OH clinician and their patient. While the hospital patient expects their appointment to result in diagnosis and treatment to alleviate symptoms or cure illness, the OH patient may be expecting a less “patient-centred” approach. Their appointment may have been instigated by, and result in a report to, their manager. The information provided by the manager, and the questions posed, may reflect difficulties in the workplace that go beyond health. Despite these differences, the OH patient group consistently scored their experience more highly than the NHS group.

Although OH patients may differ in many ways from hospital outpatients, there is a strength in being able to benchmark the OH specialty’s findings at a national level using established tools and results from another large cohort of outpatients.

Reviewing problem areas

These findings are a testament to the consultation skills of OH clinicians and the management of their services. Services with poorer results than the national average should review the particular areas that let them down and take action to improve their performance. Regardless of how good their results are, all OH clinicians and departments should review their results and strive to achieve even higher patient experience scores in the future.

There is evidence to show that good occupational health promotes a healthy, safe work environment, which leads to high levels of staff engagement and, in the healthcare sector, positive patient outcomes, such as high patient satisfaction scores and ­lower rates of patient mortality. All NHS OH teams should share the results of this survey with their board.

This project was funded with the help of contributions from NHS Plus, the Academy of Medical Royal Colleges and the RCP, and overseen by the HWDU Audit Development Group.

Dr Sian Williams is clinical director of the Health and Work Development Unit and a fellow of the National Institute for Health and Clinical Excellence.

References

The national outpatient survey 2011

The national occupational health patient experience survey 2011 

Table 3: Overall impression
Overall, did you feel you were treated with respect and dignity while you were at the OH department?
	National outpatient survey 2011	National OH survey 2011
Yes, all the time	89%	98%
Yes, some of the time	10%	2%
No	1%	0%
Overall, how would you rate the care you received at the OH department?
	National outpatient survey 2011	National OH survey 2011
Excellent	44%	66%
Very good	39%	29%
Good	12%	5%
Fair	4%	1%
Poor	1%	0%
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