In an innovative approach to providing OH services from primary care, a GP
partnership has shown how occupational health care can work within a general
practice setting, by Helen Clinkard & James Heffer
When the NHS was founded, occupational health was not included. Fifty years
on, the question of who provides occupational health and how it is provided is
still being asked.
With the restructuring of major manufacturing industries, many OH doctors
and nurses have gone and OH provision is being provided on a contracted-out
basis. Provision by the private sector has ongoing problems linking with other
healthcare professionals and tends to be driven by health surveillance needs.
As far as we know, there is no comparative data comparing different
arrangements of OH provision in terms of outcomes, cost or quality of service.
However, we offer an overview of one arrangement that we believe may have
several advantages over conventional arrangements for both user and provider.
Most employees with occupational health problems, ‘usually first consult
their general practitioner’.1 It would therefore seem reasonable to develop an
OH system that had strong links with, or was based in, primary care.
This positioning of the service would also reflect the current drive to make
OH care more accessible to employees, which is at the core of the Government’s
policy for occupational health, Securing Health Together.2
History of the practice and service
The Bradford-on-Avon Health Centre practice has been involved in
occupational health work for several decades.
This initially took the form of an appointment of a factory doctor to a
local company.
About five years ago, it became clear to the practice that companies would
require a higher degree of skill and professionalism from their OH providers,
not least because of the increasing legislative load, particularly from EU
directives being absorbed into UK practice.
It was also clear that occupational health remains very much a a nurse-led
profession and the practice wished to reflect these developments in the service
it was providing.
As a consequence, the decision was made to fundamentally change the pattern
of working. Two GPs obtained the Diploma in Occupational Medicine and the
practice recruited a part-time occupational health nurse (OHN).
The practice initially used the nurse to enhance the service it already
offered to one local company. It soon became clear that this arrangement
resulted in a better service for the company. This was borne out by the company
secretary, who said: "Occupational health has become a proactive service,
working with management to identify problems, helping the employee and thus the
company; a win-win situation for us."
The service became more accessible to the workforce, there was a
transformation in the standard of record keeping and, from the company’s
viewpoint, the management of absence improved, with a 30 per cent reduction in
total absence over two years and a saving in sick-pay costs in excess of
£100,000 per annum.
The improvement in performance was so marked that it encouraged the practice
to offer the service to other local companies. The organisation has since grown
steadily, recruiting staff to match the expanding client list.
The current service
The current client list covers a wide spectrum of employees, including
manufacturing, the service sector and the public sector. It includes some
household names as well as small and medium-size enterprises (SMEs). All the
organisations served are close to the practice, being in or around west
Wiltshire.
The organisation offers a service menu to clients. This can range from an
in-house OH nursing service, with direct access to physiotherapy and
counselling, to individual items of service more suited to the requirements of
SMEs. Collectively, the clients cover an employee population of about 4,000.
Quality standards
The organisation is part of the NHS Plus scheme, which encourages NHS
occupational health teams to provide services to the private sector,
particularly SMEs. The organisation is also part of an offshoot pilot scheme
evaluating the potential contribution of general practice to NHS Plus and to OH
in general. We hope to be one of the first organisations to have our standards
of service audited as part of this pilot.
Perceived advantages
The advantages of delivering OH care in this way stems from possessing
detailed knowledge of the local health economy, its general practitioners,
primary care teams, hospitals and consultants. Excellent relationships with
local healthcare professionals including nurses, physiotherapists and
psychologists can be built. Being part of the local NHS means that long waiting
times for operations or investigations are known to us and companies can be
advised accordingly. The organisation has extensive knowledge of local, private
healthcare providers, their costs, services and standards.
In promoting the practice’s local knowledge in support of the OH work,
ethical matters relating to overlap between employees and practice patients
must also be taken into account.
The team is punctilious in explaining to any employee the distinctive
characteristics of the OH role, and, in particular, that the OH physician is
not the patient’s advocate in the way that a GP may be perceived. This deals
with the vast majority of potential problems.
The backing of a group general practice means that on the rare occasion that
an ethical problem cannot be resolved in this way, the patient can be referred
to another GP within the practice. All OH documentation is kept completely
separate from any other medical records in the surgery premises.
Working as an OHN within the setting of general practice is exciting and
challenging. It includes the whole spectrum of OH, from risk assessment and
health surveillance to sickness absence management in a variety of different
settings and different cultures.
There are currently three OHNs on the team; one has the OH certificate,
another is starting her OH diploma in September and the third is working
towards a BSc (Hons) to become an occupational health nursing specialist
practitioner.
The practice is currently recruiting for more staff and is offering OH
training as part of its employment package. The senior adviser role is changing
to become more focused on management and having greater involvement in policy
making, procedures and training; for example, in training employees in health
surveillance, such as skin surveillance programmes and health promotion.
There is the opportunity to work in varied environments. These include the
rubber industry, which has an ageing workforce, where the employees have worked
in the industry for most of their lives. In contrast, there is a company
running a call centre that has a very young workforce and a high turnover of
staff.
These are examples of a wide variety of work-related experiences that give
an all-round knowledge of the working environment in different cultures, rather
than being isolated in one OH nursing speciality.
One of the advantages of working for a general practice is having the
support of the whole primary healthcare team. The doctors are very supportive,
and work alongside the OHNs, helping the whole team in a proactive manner.
Nobody feels isolated. Good practice is shared and team working encouraged.
Working in a primary care setting also enables staff to think beyond just
the client’s workplace. For example, when planning a health promotion campaign,
the local target areas can be identified through consultation with other
healthcare professionals within the team. This broadens the OHN’s knowledge.
The doctors in the practice have a good working relationship with other
general practices in the area and this can be very handy for getting letters
back from the employee’s GP sooner rather then later. It also opens up a
channel between the local general practices and local industry.
The practice is now planning open lunchtime sessions for healthcare
professionals at the companies to whom it provides OH services. These will
enable local GPs to meet the organisations their patients work for, thus improving
the understanding of local industry and the risks to which employees are
exposed. It will also act as a forum where issues such as rehabilitation and
the use of medical certification for workplace absence can be discussed.
Our OH team sees the involvement of local general practices as crucial in
developing future OH provision nationally and is keen to look at different ways
in which practices might be involved.
The disadvantages have been few, but mainly related to communication – the
fact staff are working out in the community and not based at the surgery
premises. However, the OH team now has regular meetings at the practice. This
helps encourage communication between practice staff and OHNs.
The practice feels privileged to have been at the start of this new and
exciting project. Occupational health certainly sits very well within general
practice and it has enabled the OH team to use all its skills to provide a
first-class service for employees in west Wiltshire.
Conclusion
We consider that Bradford-on-Avon Health Centre has created a viable model
for basing occupational health care within a general practice setting. This
could form the basis of a long-term strategy for reaching out to industry
locally and to SMEs in particular. It offers exciting employment prospects for
OHNs, making them part of the primary care team and offering them a variety of
workplace settings.
The new general practice contract, if approved, may give added impetus to
this arrangement of providing OH care, by permitting financial support to
practices offering this service. We hope other OHNs and GPs will be encouraged
to explore the possibilities presented by this model.
References:
1. Snashall, D (ed), Hazards of Work, The ABC of Work Related Disorders, BMJ
publishing, 1997
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2. Health and Safety Executive, Securing Health Together, 2000
Helen Clinkard is the senior occupational health adviser to Bradford-on-Avon
Health Centre Occupational HealthServices. James Heffer is the lead GP for
occupational health at the practice.Bradford-On-Avon Health Centre,Station
Approach, Bradford-on-Avon, Wiltshire, BA15 1DQ, tel: 01225 866611
