Flying the flag for women’s health

Marks & Spencer’s breast screening programme predates the NHS’s scheme,
and is still going strong after more than 27 years, by Nic Paton

Marks & Spencer is known for many things: iconic high-street retailer,
supplier of underwear to the nation, Per Una. But its breast-screening
programme for employed and retired staff is probably not something that is high
up on the recognition list.

Yet, Britain’s favourite high-street retailer has offered breast screenings
every two years to permanent female staff aged 40-70 for more than 27 years,
making its national scheme older than the NHS’s breast screening programme.

The service uses 68 providers from both the NHS and the private sector, and
is seen as an important health benefit, as Dr Anne Price, head of occupational
health, explains. "Occupational health has acted as the custodian of the
programme, ensuring the clinical quality of the service, administering the
delivery and maintaining the data obtained," she says.

M&S’s OH teams in the field support the running of the programme and
provide rehabilitation advice for those diagnosed with breast disease or breast
cancer. "The programme picked up 65 new cases of breast cancer in the
workforce this year alone," says Price. "Remember, research has shown
that early diagnosis improved prognosis in this common disease."

Until November 2000, the company also offered a cervical cancer-screening
programme, delivered in the stores by the store doctors. This began in 1968,
again pre-dating the NHS programme.

"We realised over time that the NHS cervical screening programme was
very effective, and hence felt able to stop offering this service in the

"Transfer of all staff from the M&S programme to that of the NHS
went very smoothly," says Price.

With more than 350 stores around the country, a turnover of £8bn and 65,000
staff, Marks & Spencer has come a long way from the stall opened in Leeds
by Russian-born Polish refugee Michael Marks in 1884. Ten years later, he
formed a partnership with Tom Spencer, a former cashier in L J Dewhirst – the
rest, as they say, is history.

The chain’s health provision has changed a lot over the years, too. The
service was initially very much about providing primary care and was delivered
by local general practitioners.

"Even when I joined as a store doctor 11 years ago, providing services
to Newmarket and Cambridge stores, it was still aimed at ensuring employees
were receiving good and appropriate primary medical care. Stores still had
chiropody and dental care provided to them," Price explains.

At present, the occupational health service in the field is delivered by 54
contracted doctors, largely local GPs with an interest or qualification in
occupational medicine. This equates to approximately eight full-time equivalent

"The doctors themselves, because of their other work, bring additional
skills such as well-informed clinical skills and disability assessment,"
says Price. "Their local knowledge about NHS services and provision is
also crucial."

"A major boost to the service came over the past 15 years or so with
the introduction of occupational health advisors into the business," she
adds. The 57 OH advisers (OHAs) and OH practitioners work together closely as a

Price became head of occupational health three years ago and in that time,
above and beyond providing the day-to-day service, she and her team have
focused on delivering a number of specific programmes to target the
occupational health needs of the M&S workforce.

"Last year, we developed risk assessments for pregnant workers – 80 per
cent of our workforce is female. We also revitalised our approach to the
clinical aspects of food handling, as food is such an important and essential
part of our business," she explains.

A large piece of work in 2002 focused on mental health problems in the
workplace – an area that, despite being common in the population at large and
in the workplace, is often not dealt with as effectively as physical illness,
in occupational health terms.

Mind Out for Mental Health

In setting up the programme, the company worked closely with the
Government-sponsored charity Mind Out for Mental Health. OH teams were sent on
two training days, where their skills were updated by consultant psychiatrists.

Training was focused on looking at modern approaches to common mental
illness and how modern treatments impact on recovery and prognosis. The idea
was that, with more up-to-date knowledge, OH could inevitably give better
informed advice to management before employment, during rehabilitation and also
in relation to ill-health retirement.

Another key element was challenging any personal views or pre-conceived
ideas about mental illness among the OH team using the Mind Out for Mental
Health’s ‘ambassador scheme’. This is where someone who has suffered an episode
of mental illness talks about the impact it had on their lives.

"A powerful picture is painted of how clinical agencies, employers and
work colleagues react to a diagnosis of mental illness. It made us all reflect
on our own practice and attitudes in a very effective way," says Price.

She also worked with organisational psychologist Steve Williams to develop a
programme called WorkWell, which is being delivered to a pilot group of line

"It was becoming clear that, as the nature of the business was changing
and the role of line manager was introduced to replace the supervisory role,
certain skills were not being developed in line managers. In general, the
people-related skills were being neglected in an attempt to increase commercial

She explains that OHAs go out into the field to deliver the modular
programme to groups of section managers.

Although four hours in total, each module can only last 20 minutes, to make
it adaptable to the pressures of a commercial setting. Subjects covered
included handling difficult relationships and delivering difficult messages.

"So far, about 1,000 line managers have been through the programme, and
initial results are very encouraging. A further 1,000 managers will attend the
workshops and then, a full evaluation will be undertaken. But already we have
some fascinating data that will help shape future training and development for
line managers," says Price.

Violence in the workplace

While the mental health programme has continued, in 2003 the focus shifted
to violence in the workplace and musculoskeletal problems.

Violence is a growing issue in the retail sector – something Price feels
badly needs to be addressed. "A lot of people are leaving retail work
because of increasing concerns about violence," she explains. "Our
own experience also shows that violence and aggression by the public to staff
is on the increase. It may be verbal, it may be physical but it is still

"It is more difficult to ‘design out’ violent attacks in the way that
banks and building societies sometimes have, because we want people to come
freely into stores. Society is more aggressive and demanding which, coupled
with drug and alcohol-related behaviour changes, makes incidents more
threatening than before."

The role of OH in this area was seen as providing a ‘therapeutic response’
to staff subjected to violent or traumatic events, with company first-aiders
acting as the first-line response.

"First-aiders are available in all stores at all times. They already
have certain skills and attributes as part of their selection and
training," Price explains. "So we built on these skills by giving
additional training in ‘psychological first aid’ to complement the physical
aspects of first aid that they were already familiar with."

A patient leaflet was also produced and given to first-aiders. This could
then be given to staff who had suffered violence. It also helped to emphasise
that there was a friendly face to which the victim could turn.

"Everyone knows these people, they are their colleagues. It is unusual,
but so far it is working very well. You have to be pragmatic because these
episodes can occur at any time. Because you give the individual the leaflet to
read, they can come back to it again," says Price.

"I think one of the most important things is that they can give it to
their families to read so that they understand why they are behaving
differently and why they are feeling this way about what has happened to

Managers also liked the booklet because it helped to take some of the
responsibility for what is a very difficult area off their shoulders.

Another advantage is that it has created a hierarchy of response, says
Price. If appropriate, a referral into the OH team can be arranged by the
first-aider, and if necessary, a referral on to a physician, and then even, to
a trauma specialist.

"It means we can give a level of service across the whole workforce at
any time of day," says Price. "Most people will not need anything
more. A tiny percentage will need to be taken to a higher level, but it means
you are not using that rather complex and discredited debriefing approach that
has been so controversial," she explains.

The scheme has been so successful that BT is interested in using the model
for its own operations.

Tackling MSDs

The other big project for 2003 was musculoskeletal disorders (MSDs), with
the focus on improving the skills of the OH team in diagnosing and treating
such disorders and providing better tools for them. Again, the answer was seen
in a combination of improved training and the development of a patient leaflet.

So far, the majority of the training has been carried out with M&S
borrowing a Sema Schlumberger training video on how to do a thorough
musculoskeletal disorder assessment and also making use of resources from the
National Back Pain Association. The leaflet ‘goes live’ this month, and will be
available to staff members assessed by the OH team.

Price came to Marks & Spencer from the agro-chemicals industry, starting
her commercial life as a works physician for what is now Bayer. But in
February, she is set to move back into the NHS, taking up a consultant post at
Hinchingbrooke NHS Trust, which covers hospitals in Hinchingbrooke, Papworth,
Peterborough and Kings Lynn. A key part of her new role will be helping to
develop OH services to GPs – an area that has long been ignored by the NHS.

"For me, it is like providing services to lots of small shops because
each GP practice is like a small business. So I’m hoping what I’ve learnt here
will help me," she says.

Keeping track of health

The development of its Occupational Health Teams Reporting Activity, known
as OHTRA, is the programme she is most proud of at Marks & Spencer. This
database of work-related illness can be used by OH physicians and advisers to
look at trends, tasks people were doing when they became ill, types of job,
age, sex and so on. As time goes on, she believes it will become an invaluable
resource across the company.

"Over the summer, for instance, we saw a real upsurge in skin
dermatitis, which had a lot to do with the nylon outfits and the heat.

"If you think about it, you could almost have predicted it, but when
you get the data you can say: ‘well, let’s change the material we are using in
our uniforms’," she explains.

OH at Marks & Spencer nominally sits within HR. But generally – and not
just within Marks & Spencer – it can play a much more pivotal role within
organisations, she argues.

There is a growing recognition among business leaders that, when health
issues are fed into the commercial domain, they can improve areas such as
productivity, absence and retention. But OH still needs to be at the
decision-making table earlier, she suggests.

"I think that OH will become much more utilised by the commercial side.
If changes are going to come, it is important they are discussed in advance. If
new equipment is going to be coming in, it should be discussed in advance.

"In the chemical industry, no changes could be made to the plant or
equipment without a tick in the box from occupational health so that the health
aspects were considered," she says. "We can often prevent costly
mistakes, and often what you are saying is what the workforce would say if
anybody bothered to ask them."

Because OH straddles both the business and health worlds, it can act as an
aid to solving a problem, and as a conduit between employee and employer, Price
suggests. "You can sometimes act as a translator, but you have to remember
that the manager’s knowledge of medicine or health issues is a lay person’s
knowledge, so you sometimes have to really explain what that means – not in
medical terms, necessarily, but in functional terms.

"The other benefit is being able to see the problems coming and predict
issues that they might not have been aware of until it was too late", she

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