Pre-employment health assessments are widely used in NHS trusts, despite the evidence of a large-scale audit in 1993 which questioned the value of their use on the basis that employees are rarely found to be unfit for work.9 This questions whether such screening is a good use of OH time and resources. Furthermore, the assessments appear to be unnecessary when many of the questions in pre-employment questionnaires are also covered by legal regulations requiring employers to undertake risk assessments of all staff, regardless of whether they have a pre-existing health condition.
OH professionals in Sandwell and West Birmingham Hospitals (SWBH) NHS Trust have reviewed pre-employment questionnaires used in a local hospital and carried out an audit of the resources required to carry out pre-employment screening, as well as the outcomes of the process. They also estimated the cost of pre-employment screening by the trust’s OH and safety services (OH&S).
It concluded that pre-employment health screening could be eliminated for most employees, and that decisions about fitness to work could be made by human resources managers using three questions and a simple matrix.
This article explains how the reviews and audits were carried out, and why these conclusions were reached.
SWBH Trust’s OH&S pre-employment protocol is based on guidance found within a number of widely accepted documents.1,2,3,4,5,6,7,8 It defines the reasons for pre-employment screening as follows:
- To advise an employer on any adjustments which should be considered to assist an individual to undertake a role or specific tasks safely, whether or not the Disability Discrimination Act applies
- To ensure specific standards of fitness are met where there is a legal or safety obligation to do so
- To provide baseline data for future assessments
- To form part of a job offer for the employer, as required by HR.
The occupational health and safety service carried out a simple exercise to determine views on the value of the questions in a pre-employment form used by the Royal Free Hospital (RFH). Although the sample size is small, the results are interesting.
The method used
Clinical occupational health team members were asked to complete the 24-question Royal Free Hospital pre-employment form, then to judge whether or not they thought each question was of value, qualify their opinion, and explain what action they would take if a candidate response indicated that there may be an impact upon their medical fitness for the post offered. Questions that more than 60% of the respondents indicated would be helpful were refined, and a second questionnaire was developed. This was distributed to the same team members, who were then asked to repeat the process.
In addition, the OH team examined an audit report dealing with aspects of pre-employment screening, and also carried out an evaluation of the estimated costs of OH nurse salary information and administrative time using data from the audit report and departmental records.
Fifteen clinical OH team members were asked to participate in the first survey, and 11 completed and returned it, with 13 of the 24 questions thought to be of value.
Questions considered to be of little or no value included asking whether an individual had vision problems and when they had last visited an optician; whether an individual had hearing problems and whether they used a hearing aid; and if they had seen a doctor in the past year for a health problem, or whether they had ever had joint problems (see box, left).
In addition, the questions asking whether someone had ever had treatment for tuberculosis or had ever had hepatitis or jaundice were also thought to be of low value. And the questions asking the individual to declare their height and weight were thought to be irrelevant by the majority of this group.
One qualitative comment made by the respondents on such questions was: ÒThe client may not disclose or may be untruthful.Ó This is salient as paper questionnaires can only be taken at face value, and the information disclosed is only relevant at the time it was written. A fully fit person could complete the health declaration form and after posting it could be seriously injured, or diagnosed with a disease.
Actions which clinicians said they would take if a candidate declared some of the health conditions included:
- Determining the relevance to the job/safety-critical factors
- Considering adjustments
- Determining whether the condition is current
- Considering a health interview/referral to GP or OH physician
- Contacting the candidate by phone for further information.
The same 15 clinical OH team members were asked to participate in the evaluation of the refined questionnaire, and seven responded.
A separate examination of a recent audit document, carried out by the same trust, revealed that in the two years from 1 April 2003 to 31 March 2005, a total of 4,482 pre-employment forms for acute NHS trust staff, primary care trust staff and mental health trust staff had been scrutinised. Of these, advice was only given to managers about making adjustments in 6.6% of cases (see table 1, left). It appears that nobody was denied employment because of health concerns.
Advice sent to managers, with employee consent, regarding employment support or adjustments was examined further. A random selection of 30 of these files (representing a 10% sample) were examined to determine the type of advice given to managers. (see table 2, left).
As an employer has an obligation to ensure that all employees have appropriate moving and handling training, is required to undertake display screen equipment assessments, provide first aid and address specific work stressors, much of the advice given in the sample is likely to be superfluous to requirements. The exceptions are the two cases where specific adjustments under the Disability Discrimination Act were required, and where health surveillance follow-up was necessary.
This raises the question of whether the advice was given to protect the OH adviser rather than the employee. We propose that a further in-depth study of the value of this type of advice to managers should be carried out in the future.
Estimated screening costs
It takes an OHA approximately two minutes to scrutinise a form, and perhaps five minutes to follow up with a telephone call to retrieve missing information. Health interviews, should they be required, have 30-minute appointments allocated, with letters of advice taking approximately five minutes of dictation time.
In addition, all the forms must be registered on a database, and the administration staff responsible often spend time on the telephone trying to establish who the appointing officer is, and have to type the letters, make appointments and change them when they are inconvenient, or when individuals fail to attend. Taking into consideration this information, the estimated average time to deal with a single pre-employment form is 15 minutes. Therefore, the estimated time to process the 4,482 pre-employment forms for the trust during the audit period was 1,120 hours.
As well as processing NHS pre-employment forms, the service processed more than 8,000 forms for a major contract during the same period as well as several hundred for smaller contracts, resulting in a further estimated 2,000 man hours, making a total of 3,120 hours.
In this one year, an average of 1,560 hours were spent processing pre-employment forms. A full-time OH adviser is contracted to work 1,950 hours per year, but only 1,665 hours are actually worked, allowing for annual leave and bank holidays. The combined administrative and nursing time per year allocated to the pre-employment screening process equates to almost one full-time OH nursing post. The costs, based on an experienced AfC band 6 OH adviser with a salary of £24,198 to £30,247, are significant.
Discussion and conclusions
The evaluation of the pre-employment form revealed that many of the questions asked are addressed by legislation. As there is a legal requirement for employers to comply with Control of Substances Hazardous to Health regulations, first aid regulations and display screen equipment regulations, they are obliged to undertake all of the necessary risk assessments for an employee, regardless of whether they have a pre-existing health condition.
In addition, the Disability Discrimination Act requires employers to make adjustments for disabled staff, and this underpins good OH practice. This raises the question of whether any occupational health practitioner would really turn someone down for employment or make recommendations for adjustments for someone who stated they had not had an eyesight test within the past two years, or failed to declare their height or weight.
Because of the legal requirements, employers could ask three simple questions to prospective staff as part of the recruitment process, and refer on to OH for further advice if the answers are affirmative (see table 3, left). Responses could be assessed by HR using a simple decision matrix.
In 1993, Whitaker carried out a national audit of pre-employment assessments in the NHS.9 The pilot study, which examined a total of 996 pre-employment forms, found that one person (0.1%) was found to be unfit, with 14 (1.4%) having some restrictions. However, 981 (98.5%) were found to be fit. At that time, the value of pre-employment health assessments was questioned.
Carol Hargreaves is an occupational health nurse manager at Sandwell and West Birmingham Hospitals NHS Trust. Acknowledgements to: Dr Paul Grime and Royal Free audit group; Mary Clayton, OH research nurse, SWBH NHS Trust
1 Cox, R A et al (2000) Fitness for Work, fourth edition. Oxford Medical Publications
2 Department of Health (1998) The management of health, safety and welfare issues for NHS staff NHS Executive Wetherby
3 Disability Discrimination Act 1995
4 Faculty of Occupational Medicine (2000) Occupational Health Guidelines for the Management of Low Back Pain at Work, London
5 Joint Tuberculosis Committee of the British Thoracic Society (2000) Control and Prevention of tuberculosis in the United Kingdom, Code of Practice
6 Department of Health (1996) Immunisation against Infectious Disease, London HMSO
7 Department of Health (2001) The Effective Management of Occupational Health and Safety Services in the NHS, London HMSO
8 Department of Health (2001) NHS Plus London HMSO
9 Whitaker S, (1993) National audit of pre-employment assessment in the NHS, Occupational Health May p173-175
10 Clothier C (1994) The Allitt Inquiry: Independent Inquiry relating to deaths and injuries on the childrenÕs ward at Grantham and Kesteven General Hospital during the period February to April 1991, London HMSO
11 Dunn L. (2005) Fit for the job, Occupational Health, Vol 57, number 9, pages p21-23
- Have you ever had vision problems?
- When did you last visit an optician?
- Have you ever had hearing problems?
- Have you ever used a hearing aid?
- Have you been to see a doctor in the past year for a health problem?
- Have you ever had joint problems?
- Have you ever had treatment for tuberculosis?
- Have you ever had hepatitis?
- Have you ever had jaundice?
- What is your height?
- What is your weight?
Recommendations on pre-employment screening
- Pre-employment health assessments should continue where there are safety-critical standards to be met; for example, for healthcare workers undertaking exposure-prone procedures, or drivers required to meet Driver and Vehicle Licensing Agency group 2 standards.
- Consideration should be given to eliminating the requirement for pre-employment health assessments for the majority of workers.
- Three simple questions addressing individual workplace needs could be incorporated into the recruitment form issued by HR (many recruitment forms already address the Disability Discrimination Act).
- Fitness could be assessed by human resources personnel using a decision matrix.
- Consideration should be given to repeating WhitakerÕs National Audit of pre-employment screening in the NHS. Alternatively, a regional audit replicating the methodology of WhitakerÕs national audit could be considered. This may be undertaken by one of the SWBH occupational health specialist registrars for the MFOM qualification.
- A research project within the trust to determine the value of advice supplied to managers as part of the pre-employment process should be considered.