Course of treatment

With
occupational health on the government agenda and targets to be met in every
workplace, until recently the primary care sector was seen to be lagging. But a
pilot scheme to help the profession progress its OH provision has proved a
success.  By Lesley Abbott and Sue Burke

The
HSE document Working Together: Securing a Quality Workforce for the NHS1,
highlights "creating healthy workplaces" and targets April 2000 as
the date by which the following should be achieved year-by-year improvement on
sickness absence rates and, where applicable, targeted progress towards
national minimum benchmark.

Have
systems in place to record and monitor workplace accidents and violence against
staff and have published strategies in place to achieve a reduction of such
incidents. Have in place occupational health services and counselling available
for all staff. This message from the Government is clear and one that has been
acted upon in the vast majority of NHS trusts. It is therefore all the more
surprising that our colleagues in primary care have been left by the wayside
with little or no occupational health provision.

Clinical
governance

The
introduction of clinical governance2 will inevitably put pressure on primary
care staff to introduce rigorous systems of clinical and managerial quality
control. Procedures for dealing with poorly performing staff will inevitably
raise questions regarding possible ill-health of the individual. This provides
a further compelling reason for primary care to invest in a robust and effective
occupational health service.

The
absence of occupational health services in primary care has started to be
addressed in a variety of ways in different parts of the country.

In
south and west Devon, due to the vision and persistence of Dr David Longdon, a local
GP, and supported by consultant occupational physician Dr Gerard Woodroof,
funding has been released to support a pilot scheme to provide a proactive and
comprehensive occupational health service to GP’s and all practice staff.

Project
strategy

AbbottBurke
Associates has been employed on a consultancy basis to establish and develop a
comprehensive occupational health service tailored to meet the specific needs
of primary care staff. Directors Lesley Abbott and Sue BurkeLongdon together
with Longdon and Woodroof formed the project group with the aim of developing a
strategy and taking the service forward.

The
original vision for this extended occupational health service included a core
service of OH provision, supported by an already well established network
within Devon of GP mentorship and support for new principal GPs, plus a Local
Medical Council which demonstrated its commitment to the principles of
occupational health.

It
would have been relatively easy for the team to develop an occupational health
service which made assumptions about the needs of primary care staff based on
the individuals’ knowledge of other NHS workers or using data from  previous research3,4. Instead a keenly
targeted approach was adopted to offer a service which did not rely on
pre-conceived and conventional systems but sought to be evidence-based and
innovative.

The
team felt it was important to visit practices and talk with doctors and their
staff in order to build links and discover what the main occupational health
issues were for primary care.

Analysing
needs

It
was no great surprise to find that the occupational health and safety needs
within primary care are very different to those in NHS trusts, and indeed are
more akin to small- to medium-sized businesses providing services to an
increasingly demanding clientele.

The
occupational health needs also vary in different areas of the South West from
rural to city settings and single-handed to multiple partner practices.

As
in many other work areas, occupational health is not well understood in the
primary care sector and has been greeted by reactions ranging from positively
hostile, through ambivalent/suspicious, to delighted and relieved that a burden
may be removed. But as the team continues to publicise the service and
demonstrate its effectiveness, opinion appears to be moving towards the
"delighted" end of the spectrum.

Specific
concerns

One
of the main concerns of staff, but particularly of GPs, is confidentiality. A
GP who is sick, is afraid that they will lose respect, standing and possibly
their livelihood if patients and colleagues have the slightest glimpse of any
underlying medical condition.

Such
fears about confidentiality become exacerbated as anxiety increases and makes
it difficult for the individual to seek help.

The
fact that the project coordinators are based some distance from the service
users is seen as a means of furthering the confidentiality and impartiality of
the service. The service also has the support of and direct access to a
consultant psychiatrist and a psychotherapist to whom GPs may be referred in
total confidence.

Comprehensive
service

The
elements of a comprehensive and proactive occupational health service are relatively
new to GPs and other primary care staff. Ruth Chambers, professor of primary
care development proposed a national model in November 1975, in which these
essential elements are defined. We consider that our model combines both the
essential elements, plus added-value by:


Development of systems that diminish areas of ambiguity between staff and
therefore reduce stress and save time. For example, the handling and follow up
of an incident involving an aggressive and abusive patient.


The perception that staff are cared for. For example, any individual is
encouraged to make direct contact with any aspect of the service in total
confidence whenever they feel the need.


Financial benefits. Staff who are off sick or are in a partnership dispute cost
the practice money. This can be reduced by the use of carefully developed
systems saving time and emotional effort. Impartial and independent
intervention in incidents that arise when a member of staff is registered as a
patient at their own practice and becomes ill.


Support for staff in the management of change. This is particularly pertinent
in the current transition to primary care groups and ultimately trusts.


Communication. There is open access to the service by e-mail, answer phone and
a dedicated period for direct telephone contact. Service users are encouraged
to request a practice visit from the coordinators to address specific personal
or practice issues. The visits are mutually beneficial first-hand experience
and information gained from the visit can be used to inform and enhance the
occupational health service as it develops.

Practices
gain from direct access to professional knowledge and expertise. An effective
use of time, for all concerned, is meeting groups of staff to listen and advise
on their specific needs for example regional practice manager meetings and
individual practice meetings.

The
meetings also offer the opportunity for education and training on more specific
issues. This is particularly helpful following the introduction of new policies
and procedures or initiatives – for example, pre-employment health assessment
and managing violence and aggression.

The
service publishes a regular newsletter that is aimed at all practice staff,
which publicises the service and informs readers of developments and future
plans. Contributions from external agencies are regularly featured to support
current service initiatives and drives – for example, the Suzy Lamplugh Trust
supporting personal safety issues.

Every
opportunity is taken to publicise the service to both current and potential
service users, an important aspect of any pilot scheme, particularly in
relation to sources of future funding and support.  Such an opportunity is presented at the South and West Devon
Primary Care conference in February with presentations, workshops and an
exhibition stand.

Firm
foundation

Good
communication is the vital lynchpin in assuring the ultimate success of a such
a complex and diverse service. The team works hard at marketing the occupational
health message strategically so that it informs, feeds and motivates both
service users at ground level and those who have the responsibility of
developing national health policy.

There
is an almost tangible synergy within a practice where staff are healthy,
communicating well and confident of the constant support of a reliable
occupational health service. Occupational health and safety systems which
provide organisational support, reduce the need for GP or practice manager
intervention every time something out of the ordinary happens.

The
pilot team believes that the Occupational Health Service for Primary Care for
Devon and Cornwall has put in place a firm foundation upon which such a service
can evolve and grow.

Lesley
Abbott and Sue Burke are directors of AbbottBurke Associates, an occupational
health consultancy

References

1
HSC (1998). Working Together: Securing a Quality Workforce for the NHS. NHSE.
(HSC 1998/162)DoH

2
HSC (1998) A First Class Service: Consultation document on Quality in the New NHS,
(HSC 1998/113)DoH

3
Chambers R, Miller D, Tweed P and Campbell I (1997)  Exploring the Need for an Occupational Health Service for Those
Working in Primary Care. Occ Med,47,8pp485-490

4
Health Education Authority (1996). NHS Staff Needs Assessment: A Practical
Guide.

5
Chambers R (1997) Occupational Health Services for GPs – A National Model.
Royal College of General Practitioners.

Pilot
objectives


Project launch


Establishment and maintenance of communication


Field work


Development of generic occupational health and safety policies and protocols


Practice visits and assessment of OH&S needs – where appropriate


Access and referral to the service for all primary care staff


Monitoring and reporting


Review, future strategy and direction


Getting the service up and running

Essential
elements of an occupational health service for primary care


Easy access


Confidentiality, independence and impartiality


Pre-employment health assessment


Independent medical opinion


Management of potential or actual occupationally acquired infections


Assistance in complying with health & safety legislation


Occupational immunisation programme


Advice and support in the event of workplace accidents and injuries


Rehabilitation following sickness or injury


Training customised to the needs of all staff groups


Counselling


Direct referral to a psychiatrist/ psychoanalyst, as appropriate

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