To explore the issues surrounding health assessment in relation to the pre-employment and pre-placement process for NHS Scotland employees, a Peer Review Audit and Benchmarking Subgroup (PABS) was established in 2005. Its aim was to set guidance and a minimum standard for pre-employment and pre-placement health assessments in the NHS in Scotland.
Guidance
As part of the quality improvement process, the PABS developed the minimum standard guidance that was both evidence-based and within the Healthy Working Lives framework.1 The guidance has taken account of the relevant legislation, and has aligned the information to the Recruitment PIN (Partnership Information Network).2 The PABS accessed various fitness standards documentation as background information including the fitness standards in the police, fire service, seafarers, teachers and food handlers.3,4,5
To comply with current legislation, a functional capacity approach rather than the traditional medical model was used. The purpose for this is to improve the efficacy and efficiency of the process of pre-employment and movement of health workers between posts/health boards. There has been a lack of evidence base for the purpose or best method, as well as variable documentation, methods, standards etc of health assessment throughout Scotland.
The PABS initially contacted NHS Occupational Health Services within Scotland and other OH services requesting sharing of information on present policies, documentation, questionnaires and processes. At the same time, a review of recent tribunal cases regarding pre-employment was undertaken to assess the impact of legislation on the pre-employment process.
Assessment
The PABS was divided into four sections:
Subgroup 1 conducted a systematic literature review for effectiveness of pre-employment screening.6 The questions that were looked at were:
Are pre-employment or pre-placement health questions an effective tool for detecting current disability or ill health, which may affect an individual’s employment or require adjustments to the job?
Are pre-employment or pre-placement questions effective at detecting future ill health, sickness absence or ill-health retirement, or individuals who are susceptible to hazards in the workplace?
The results show that very little published research on the effectiveness and the evidence that is available has low sensitivity, specificity and predictive value.
Subgroup 2 – What is the purpose of pre-employment screening?
Dr Imran Ghafur’s dissertation7 was used as the basis for this group, as it asked this key question. The research was to find the purpose stated by the total population and explore the variations between different stakeholder groups.
Subgroup 3 examined all the policies, documents/procedures from all the NHS Scotland OH departments, as well as reviewing the health declaration forms being piloted by the Association of NHS Occupational Physicians (ANHOPS).7
The aim of this was to assess the common areas of health assessment questions and also when applicants would be deemed unfit for employment. The goal was to develop a minimum standard health declaration form and supporting documents, bearing in mind the Human Rights Act (1998), the Data Protection Act (1998), and the Disability Discrimination Act of 1995 and 2005.8
After considering all of the above, a functional capacity model of assessment rather than a medical model for pre-employment health assessment was developed. The research from subgroups 1 and 2 was used as the evidence base for the development of this. The PABS also had to take into consideration the new health clearance documentation for serious communicable diseases.9,10
Subgroup 4 developed a three-level functional capacity assessment. This led on from the health declaration form, including the development of a job analysis form, a flow chart on process to measure functional capacity, and tools for assessment at each level.
The flow chart has three levels of assessment:
Level 1 is when the health declaration form comes into the OH department and is assessed by the occupational health nurse (OHN).
Level 2 is when further action required either a phone call or assessment by the OHN/occupational health physician.
Level 3 is when a full functional capacity evaluation is required by a specialist occupational therapist.
The only part currently in use is the job analysis form, which is the first part of the functional capacity approach to health assessment, and further work will need to be undertaken after the process has been approved by the human resources network for NHS Scotland. As the approach of functional assessment, rather than medical assessment, is a fairly new concept in NHS occupational health, there is very little evidence base and most of the references are from occupational rehabilitation journals from the US.11,12,13
Development of the new health declaration form
By examining all the current health declaration forms in use within NHS Scotland, subgroup 3 highlighted the common questions and attempted to group them together into relevant sections. It was noted that the number of health questions varied from 20 to 56 in the reviewed health declaration forms.
They also assessed why an applicant would be considered unfit for a post, and asked how many people had been considered unfit for a post within the past year. The main causes of being deemed unfit for the post were:
Significant mental health issues
Skin problems
Musculoskeletal problems
Inability to perform exposure prone procedures (EPP).14
The guidelines for pre-employment checks within the NHS and mental health and employment in the NHS were taken into consideration in the development of the questions.15,16,17,18
Aims and outcomes
The subgroups’ aim was to condense the number of questions and to use a functional capacity approach but to maintain the relevance of the questionnaire. To evaluate the final questionnaire, process to measure flow chart and job analysis form, a survey was arranged through the Healthy Working Lives group based at Glasgow University.
The survey aim was to establish a peer group review throughout NHS occupational health service across Scotland, and to collect constructive comments prior to the publication of the whole document. The survey was distributed in February 2007 to the Scottish Occupational Physicians Group (SOPG) and the Scottish Senior NHS Occupational Health Nurse Managers Group via e-mail.
The survey had questions relating to the three documents – all the documents were included with the e-mail for the survey. Each question had a comment box for further information to provide qualitative data as well as quantitative data, which was taken into consideration for the final health form and job analysis form.
The health declaration form and job analysis form were then refined and have been in use within NHS Greater Glasgow and Clyde, Borders and Lanarkshire since early 2008. The documentation is with the Scottish Health Department awaiting approval from the Human Resources (HR) Forum before the process is more widely used across Scotland.
Pitfalls
As the process was trialled and is currently in use across Greater Glasgow and Clyde, a few pitfalls were highlighted. It would be recommended that the HR departments understand the process and paperwork before it is implemented in an organisation, and that the managers who will be completing the job analysis forms are given guidance in its use and purpose. A managers’ guide was developed as part of the job analysis form, and has proved very useful as the same questions were being asked by the managers.
The health declaration form should be considered separately from baseline health surveillance, and if health surveillance questionnaires and tests, such as lung function or hand-arm vibration, are carried out at pre-employment or pre-placement health assessments, a health surveillance record is completed and provided to management under the Health and Safety at Work Legislation.
The entire process and outcome in terms of advice from OH is dependant on the applicant and management providing the OH department with correct and complete information.
The complete documentation will be available on the Department of Health’s clinical governance website when it has been approved. Further information and a copy of the documentation can be obtained by e-mailing [email protected].
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References
1 Healthy Working Lives: A plan for action SEHD Aug 2004
2 NHS Employers: Safer recruitment and employment
3 Food Handlers: Fitness to work. Guidelines for Food Businesses, Enforcement Officers and Health Professionals. Department of Health1995. Prepared by an expert group convened by the Department of Health following the Food Safety (General Food Hygiene) Regulations 1995
4 Medical and Occupational Evidence for Recruitment and Retention in the Fire and Rescue Service. Office of the Deputy Prime Minister. London Sept 2004.
5 Fitness to teach: Occupational health guidance for the training and employment of teachers. Department of Education and Employment. December 2000
6 Literature review for pre-employment health assessment. Madan, I and Williams , S. NHS Plus Department of Health 2007.
7 The Purpose of Pre-Employment and Pre-Placement Health Assessments in UK NHS Organisations: A Study Investigating the Views of Stakeholder Groups. MFOM Dissertation. Ghafur I. Faculty of Occupational Medicine, Royal College of Physicians. London 2007.
8 Disability Discrimination Act Code of Practice: Employment and occupation. Disability Rights Commission 2004.
9 Consultation on draft guidance on health clearance for serious communicable diseases: new health care workers. Scottish Executive Health Department. July 2003
10 Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. NICE guideline March 2006
11 Pransky, G and Dempsey P. Practical Aspects of Functional Capacity Evaluations . Journal of Occupational Rehabilitation, Vol 14, No. 3, September 2004.
12 Gassoway, J and Flory, V. Prework screen: Is it helpful in reducing injuries and costs? Work 15 (2000) Lakeland Regional health System, St Joseph, MI 49085, USA. E-mail: vflory@Lakeland regional.org
13 Frank, A.O and Chamberlain, A. M. Rehabilitation: an integral part of clinical practice. Occupational Medicine, Vol 56 2006: 289 – 293
14 Waclawski, E.R, Paterson, A and Loftus, A. Is there value in routinely obtaining a report from general practitioner as part of pre-entry health screening of students for nursing studies? Occupational Medicine, Vol 54 No 3 2004: 176 – 181
15 Mental Health and Employment in the NHS. Department of Health. 2002.
16 Pre-employment checks for NHS Staff. Department of Health. 2001.
17 Looking beyond labels. Department of Health. 2000.
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18 Poole, C.J.M, Harrington, T.C, Burge, P.S and White, A.C. Guidance on standards of health for Clinical health care workers. Occupational Medicine, Vol 52 No.1 2002: 17- 24
Further reading
Pre-employment Health Screening. HSE Guidance Note MS20. London: Health and Safety Executive, 1982.
Fitness for work : The Medical Aspects. Edited by Keith Palmer, Robin Cox and Ian Brown. Faculty of Occupational Medicine. 4th Edition 2007
Guidance on Ethics for Occupational Physicians. Edited by Drs Kit Harling, Chair, and Sue Hunt, Secretary, Faculty Ethics Committee. Faculty of Occupational Medicine. 6th Edition 2006.
Good Medical Practice for Occupational Physicians. Faculty of Occupational Medicine. 2001.
Good Medical Practice: Guidance for Doctors. General Medical Council. 2006.
