Going underground

London
Underground’s occupational health service has evolved from a back room in the
HR department to a fully-fledged 
department offering a range of services to more than 23,000 members of
staff, by Nic Paton

Back
in the 1950s, it has been alleged, a London Transport bus driver had a heart
attack and ploughed into a queue of passengers at Oxford Circus, killing and
injuring many. That is how, so the story goes, what is now London Underground’s
OH service began.

"It’s an apocryphal tale, I think, because I have
never, ever found any evidence for it," laughs Dr Olivia Carlton, head of
OH at London Underground (LU).

What
is beyond doubt, however, is the modern-day commitment to OH. The transport
network spends around £2m a year on OH, employing a 50-strong service to
provide for the health needs of some 23,000-25,000 people.

Indeed,
when you walk into LU’s OH department near Edgware Road, it is much like
entering a GP surgery, with a spacious waiting room, appointments’ desk and
consultation rooms, as well as the obligatory pot plants and vending machines.
And that’s just one floor.

Carlton
has been with LU since the late 1980s, becoming head of the service in 1994 and
transforming it from a medical outfit located within HR to a much more
substantial operation within LU’s safety directorate.

Its
new home has been very much part and parcel of pushing OH firmly up the agenda,
she says. "Both safety and HR have a very big impact on the way LU is run,
for obvious reasons. There is no question that since moving into the safety
directorate two years ago, our influence has increased. Some of that is also
reflecting the health and safety agenda being run by the Government," she
explains.

As
well as treating around 11,500 station, train, control room and management
staff, the OH team has responsibility for the health and well-being of
employees working at Transport for London, the London river buses, the people
who license and test black cabs and London Bus Services, which manages the
contracting-out of the capital’s bus routes. OH services are also still
provided to some 6,000 engineering staff, even though their operation has
recently been sold to the private sector under the Government’s public-private
partnership scheme.

The
OH department consists of a medical advisory service, counselling and trauma
service, a drug and alcohol service and access to occupational hygiene.

Medical
advisory service

The
medical advisory service, explains Carlton, has two main areas of operation:
safety, and what she describes as "productive working time".

Safety
in this context, as might be expected, is about assessing whether an employee
is fit to do their job. "To protect other employees and the travelling
public, should we let a train operator carry on being a train operator if, for
example, they had a fit last week?" she explains.

Activities
include routine and non-routine medical assessments, pre-employment medicals,
reviews with managers of sickness absence, and procedures such as hearing,
mobility and vision checks. People with heart conditions will, for instance,
have a routine ECG test.

"Do
we discriminate? Yes we do, undoubtedly, because we discriminate against
disability. But what we believe the Disability Discrimination Act says is that
you must not discriminate without good reason. A lot of our work is trying to
review whether or not we have good reason," says Carlton.

When
it comes to productive working time, the emphasis is much more on attendance,
achieved by a case management approach. LU sets targets for absence levels,
currently between 95 and 96 per cent for operational staff, and 98 per cent for
non-operational. Overall, absence rates are running slightly below target, with
some groups up to or above 98 per cent, and others well down at 90 per cent.

LU
is studying why there might be such differentials, but it’s often down to line
managers, believes Carlton. "It is not always about the busy sessions, but
about how much you enjoy coming to work. Are you properly supported when you
are at work, is it a pleasant place to be or do you dread it when you wake up
in the morning? Because that can make the difference of whether you come in or
not when you are feeling ill."

The
main medical issues the OH team deals with are stress, anxiety, depression and
musculoskeletal disorders, particularly bad backs, she adds.

After
a member of staff has been off work for a certain period of time, their case is
discussed by a member of the OH team, along with the employee relations manager
and a line manager. Individual managers will feed in to a team leader who will
then discuss a range of cases. From there, an action plan is agreed.

Two
years ago, a physiotherapy service was introduced for employees with acute back
pain. After an assessment, employees are given the options of hands-on
treatment, an exercise class or both. Bookings can be made directly by the
employee through their manager. The hope is that eventually this service will
be extended to necks, shoulders and upper limbs.

Counselling
and trauma

Located
within the OH department, the counselling and trauma team employs around 16
people and splits into two elements, generic counselling and trauma
counselling.

The
generic counselling service is based on a six-session format. The first element
of the service is a structured telephone interview with a counsellor. Between
20 and 30 per cent of those who call will proceed with this method as
counselling is not seen as offering the most appropriate way forward. Overall
usage of the service is between 5 and 10 per cent of employees.

"If
we can support people through difficulties, we can increase their performance
at work. It may sound grim, but it’s a win- win situation. We have a powerful
belief that everybody goes through times in their lives when things get really,
really tough," says Carlton.

Solutions
reached might be as simple as relaxation techniques or looking at how employees
relate to people. If after this employees need further help, OH directs them to
external agencies, which LU will pay for.

The
trauma operational staff may be exposed to comes from two main areas: somebody
trying to kill themselves by jumping in front of a train, and assaults on
staff. Suicides are, by and large, peculiar to LU and the railway network, so a
specialised approach is needed to manage their impact on staff.

London
Underground is constantly evaluating where and how often suicide attempts
happen and has drawn up information leaflets for staff. Attempts are most
commonly made at stations near hospitals treating people with mental health
conditions. The company now tries to make staff working at such stations more
aware of the problem, how to spot potential jumpers and to give them the
confidence to approach them.

LU
has a zero tolerance policy towards assaults on staff. "If the police
don’t prosecute, we do," says Carlton. "We have the absolute buy-in
from our managing director and we truly believe we need to drive forward an
organisational approach. It is not just seen as an OH or a medical issue,"
she adds.

This
organisational approach means realising there is a relationship between the
service offered and assault. "Some people just blow up, they just can’t
cope – hot day, crowded platform – and they just take a pop. It is totally
unacceptable, but if a train had come two minutes before, it probably wouldn’t
have happened. So one of our major organisational drives to reducing assaults
against staff is to increase the service we offer. So you get to the absolute
heart of our business. It isn’t just a health and safety thing," explains
Carlton.

Traumatic
incidents

"If
you take an organisational approach, you can start to see how health and safety
is totally core to your business. It just makes a huge difference to the
progress you can make."

Everybody
who has been subject to a traumatic incident is made aware of the support
services available. Funding has been approved for a trauma support group, which
used to be called a ‘buddies’ scheme, which is being led by OH in conjunction
with wider management.

OH
identifies volunteers and trains them in psychological first aid, and then duty
managers are given a list of names. "When there is an incident, the
manager will look at who the volunteers are. They will say to the person:
‘would you like to have someone come and sit with you’, and then they will ring
a volunteer who will come in, in their own time.

"The
volunteers are an amazing group of people. They will sit with that person, let
them talk if they want to, and if they don’t want to, they’ll let them be, make
sure they are warm and they have fluid, but not alcohol. They’ll explain to
them they are going to be feeling rotten for the next few days and that it is
totally normal. They may feel distressed, may not sleep properly and may have
nightmares, but it is completely normal," says Carlton.

Employees
are advised to see the trauma team, if they want to, no earlier than three days
after an incident, but within a week. They are always offered time off work but
if they feel well enough to carry on, are not prevented from doing so.

There
is then a fast-track counselling appointment, with four to five sessions taken
on average. If an employee is still showing symptoms after 30 days, a
psychologist carries out an assessment to see if they need to be treated for
post-traumatic stress, which generally happens in about 2 per cent of cases.

The
service has access to specialist counsellors in this area but, if they are not
successful, employees are referred into the NHS.

In
a recent initiative, LU is now employing an external consultant one day a week,
to look at organisational stress within the company.

"She
is going around and talking to key stakeholders about what we see as big stress
areas, but she is also working with a couple of groups who have self-identified
having serious issues, to see what she can do to help them to address those
problems, with a view to making some organisational recommendations,"
explains Carlton.

Drugs
and alcohol

In
the days of London Transport there was a heavy drinking culture within the
organisation. Nowadays, it is very different. The final element of the OH
operation is the four-strong drug and alcohol team.

LU
has a strict drug and alcohol policy that states employees will not drink at
work, will not take drugs at work and will not come to work having taken drink
or used drugs in a way that could put their work at risk. Employees cannot buy
alcohol or go into a pub if they are in uniform, and they are not allowed to
store alcohol in any operational building.

"We
back it up with a testing programme. For the uniform and safety-critical staff,
the tests are unannounced, they can be tested anytime they are on duty,"
explains Carlton. "For non-critical employees, they can only be tested if
they are involved in an incident or if their manager is concerned."

The
company tests for 1,000 drugs, with different thresholds set. If you are above
a certain threshold then a medical review takes place, with a company doctor
ascertaining whether there is an acceptable medical reason. For instance, an
employee might be taking codeine for a headache and have simply forgotten to
mention it. There is no acceptable reason for cannabis, cocaine, ecstasy or
other class A drug being used.

"If
we catch you, you are out. But if you declare you have a problem, we will
support you to an enormous extent. If 
testers arrive and that is the point you put your hand up, that is too
late," says Carlton.

Employees
who seek help can be admitted for acute detox, sent on a programme of
residential treatment or have support sessions. After-care consists of group
sessions twice a week.

If
an employee goes back to work, a formal agreement is signed that specifies the
behaviour expected of them in the future. For the next six months, the employee
is tested a couple of times a week, then reviewed.

"A
lot of them are still here 10 years later, have been promoted and made a great
success of their lives. The threat of job loss is a very powerful lever,"
explains Carlton.

Finally,
there is OH support for the OH teams. All counselling and trauma staff have formal
supervision through an external provider, which offers whatever psychological
support they may need.

There
is also an external counselling service as well as access to physiotherapy and
to company doctors.

Key
team members

Head
of OH  Dr Olivia Carlton
Medical advisory service  Blair Crichton
Counselling and trauma  Nigel Radcliffe
Drug and alcohol  Alison Dunn
Occupational hygiene  Chris Beach

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