The NHS, both as an employer and deliverer of healthcare to the UK’s workforce, is an absolutely pivotal part of the government’s vision for the future of workplace health and wellbeing in this country. That point was made clearly by Dame Carol Black in her seminal review of workplace health provision and, just as importantly, by the government in its response to her report last autumn.
A key element of that response was the announcement that there would be a systemic review of workplace ill-health within the NHS, with 10 NHS sites testing new health and wellbeing programmes for front-line staff, and close examination of how the practice and delivery of NHS occupational health (OH) could be improved.
That review, it emerged in February, is being led by Royal Mail director of corporate responsibility and chief medical adviser Steven Boorman – who is being seconded from his day job by the government three days a week – and is expected to report early findings at least in the spring.
Lack of evidence
When it comes to improving workplace health practice interventions, the problem for OH generally, and NHS OH in particular, has always been a distinct lack of robust, long-term evidence about what has worked in the past, and what hasn’t.
This is why, ahead of Boorman’s review (although it will feed into the process) the Occupational Health Clinical Effectiveness Unit (OHCEU) of NHS Plus last year carried out the first national audit of the OH care provided to NHS staff in England, concentrating on two key areas: back pain and depression. The main findings of both audits are outlined in detail below.
The audits, which were published in January, had two key messages for NHS OH practitioners: one positive and one negative, argues Dr Sian Williams, clinical director at the OHCEU. The positive element was their very high response rate, with nearly three-quarters of NHS trusts agreeing to take part, and the negative element was the finding that NHS OH is hugely variable in its delivery and practice.
“What it shows is that people want to measure their performance and want to be able to benchmark it against other trusts. They actively want to improve their performance,” stresses Williams.
“Yes, there is variation. But we would expect that because you will always get variation of resource being put into occupational health by different trusts,” she adds. “You can have anything from an all-dancing, all-singing consultant in occupational medicine to [a situation] where a trust is just visited by a local GP.”
A conference is to be held on 22 April for all English NHS OH units, where the results will be formally presented and debated.
With an organisation the size of the NHS you rarely, if ever, get quick fixes, and the audits are only the first step of the way, emphasises NHS Plus chief executive Kit Harling. “It is a long road but the main thing is that we have now started the actual audits,” he says. “Anecdotes will not drive change – only hard facts will. I think there will now be a lot of enthusiasm.”
And while the focus is clearly the NHS, there may well be useful lessons that can be learned by commercial OH providers. In fact, about 20 private organisations providing services to NHS trusts were studied as part of the audit, points out Williams.
The finding of variability was not, and should not have been, a surprise to most NHS OH nurses, agrees Dr David Snashall, clinical director of OH services at Guys & St Thomas’s NHS Foundation Trust. “But I was pleasantly surprised at the number of people who replied,” he says.
“The fact that there might be differences in the way people write things down is not a big surprise. The main message for nurses, I think, is that there is still more work to do. It is an important plank in improving services in a good way,” he adds.
The audits give a baseline, a starting point if you will, against which OH practitioners – especially once the audit process becomes more regular and established – will be able to measure their improvements in performance. What’s more, against the backdrop of health minister Lord Darzi’s continuing reform programme for the NHS, this is exactly the sort of activity that should mean OH will not be left behind or ignored, argues Williams.
In fact, as Black herself writes in her foreword to the audits, their significance is not only that they begin at last to provide a detailed picture of OH practice within the NHS, but also because they signal “a beginning, reinforcing the proper place of these services in the NHS”.
“The wide variation in practice within some trusts, with some performing extremely well, shows that it is possible that all trusts should be performing in this way,” agrees Williams.
“Clinical services and quality improvement is what Darzi is all about, and these audits fit in well within the Darzi agenda. In years to come, this type of participation will not be voluntary,” she predicts.
What the audits concluded
Both audits were undertaken last year, with 400 trusts in England being asked to submit information.
In the case of the back pain audit, the first consultation with an OH doctor or nurse was audited for employees who had a new episode of back pain. For the depression audit, it was the first OH consultations with employees who had been absent from work for at least four weeks (for any health-related reason).
The anonymised data in both cases was analysed by the OHCEU and, in addition to the national results, each participating trust also received its own local confidential results.
OHCEU has stressed that what both audits do is simply offer OH practitioners a relevant baseline. “Local results (provided to all participants) will enable occupational health services to compare themselves against best practice and to benchmark against other occupational health services across England. Each trust can use the results to identify areas in which improvements are needed, supported by the OHCEU. Future rounds of audit will measure performance against the baseline and identify further areas in which improvements could be achieved,” it added.
The unit also emphasised that, when it comes to using the data, what is being measured is a very specific area of OH practice, and therefore results cannot or should not be extrapolated as a measure of the full range of activities undertaken by that trust’s OH service.
“Each occupational health service will operate under different local circumstances. We also note that results could be heavily influenced by local policies and practice,” it cautioned.
“The OHCEU has not ranked trusts. The local results should be interpreted by each trust itself, taking into account knowledge of its service,” it added.
The back pain audit achieved a response rate of 65%, with many of the remaining trusts surveyed able to share the results obtained because many of the OH services provided care for the staff of more than one trust. However, more than half the trusts entered less than 10 cases, and so needed to interpret their local results with caution, the unit stressed.
The key finding was that there was a wide variation in practice. “There were very high levels of compliance with the Faculty of Medicine’s Guidelines for the Management of Low Back Pain in some consultations (regardless of the severity of the case), and low levels of compliance in others,” the audit made clear.
This showed that, while guidelines could be and were being followed by some OH departments, further work needs to be done to achieve more consistent standards of care nationally and, moreover, more work needs to be done to ensure that the documentation in case notes is comprehensive.
In all, 69% of the cases had been absent from work during the period audited, with most off for an average of four weeks by the time of their first appointment with an OH professional, and 44% being screened for serious spinal disease and nerve root problems.
When such ‘red flag’ issues were found, the GP or specialist was contacted within four weeks in 61% of cases, with 35% of cases also being screened for psychosocial risk factors for developing chronic back pain (or yellow flags). When yellow flags were found, they were acted upon in 80% of cases.
What these findings suggest, said the OHCEU, was that screening for red and yellow flags is not routine among all OH professionals, so opportunities to find indicators of serious spinal disease or correct erroneous beliefs that can lead to long-term back pain and disability are missed.
In three-quarters of cases, OH professionals did ask about the impact of a patient’s symptoms on activity and their work, but only asked about barriers to recovery or returning to work in half of cases.
Again, this indicated the need for OH professionals to take and document a full clinical, disability and occupational history for more of their cases, said the unit. Nearly three-quarters of consultations included an assessment of whether the back pain was caused by work, and this was thought to be the case in just over a third of these cases. Advice on further investigation of the causes in the workplace was given for 55% of such cases.
A total of 68% of consultations involved discussion about the importance of continuing normal activities, rising to 82% for the cases that had yellow flags present. While this was an encouraging finding, e_SDHpideally nearer to 100% of consultations should include a discussion about continuing normal activities, the unit advised. Moreover, the OH professional gave clear information about back pain in a form that could be understood in just 47% of cases.
Doctors and clerical staff were the least likely, and nurses and ancillary staff were the most likely to have been absent from work with back pain at the time of the audit, it was found. The OHCEU therefore stressed the importance of ensuring that all staff have full access to OH services.
The audit also questioned employees and line managers, although this section was voluntary, achieving a 20% response rate.
Nearly eight in 10 staff who responded felt they had been supported by their OH department to stay at, or return to, work during their episode of back pain, and two-thirds felt supported by their line managers.
More than half said their OH departments had contacted their line managers to help them stay at, or return to work, with 83% reporting that restrictions or adjustments to work had been recommended by the OH department. More than seven in 10 of the employees felt their managers had implemented the adjustments.
The unit argued that this suggested that there is still more scope for OH departments to educate and help managers to support their staff to stay at or return to work. What’s more, where communication did take place between OH professionals and line managers, it generally appeared to be effective, it added.
A total of 69% of trusts participated in the audit with, again, many of the remaining trusts able to share the results as they shared the same OH provider. One-fifth entered less than 10 cases and so needed to interpret their local results with caution.
Once again, the audit found wide variation in practice. There were very high levels of compliance with the National Institute of Clinical health and Excellence (NICE) guidelines on the management of depression in some consultations (regardless of the severity of the case) and low levels of compliance in others, it concluded. “This finding shows that the NICE guidelines can be and are being followed in some occupational health departments, and that further work is needed to achieve a higher and consistent standard of care nationally. Documentation in the case notes should be comprehensive,” it argued.
In total, 58% of all cases were screened for depression. However, screening occurred in a much higher proportion of cases referred for a psychological problem (83%) than those with a different diagnosis (15%). The OHCEU said this suggested that many more consultations needed to include screening for depression, particularly where the presenting problem was a physical one.
In 18% of cases with evidence of distress, the OH professional asked about six core symptoms of depression, while 11% of cases were asked about none of these.
“These findings suggest that occupational health professionals need to include more questions about the core symptoms of depression in their consultations to avoid missing depression in staff on long-term sickness absence,” the unit argued.
Nearly a third of cases with evidence of distress were asked about thoughts about suicide or deliberate self-harm, with this figure slightly higher (37%) for cases with a diagnosis of depression. Of those who reported thoughts of this nature, two-thirds were asked further important questions about their plans, and half were asked about any previous acts, the audit stressed. Therefore the management of employees with distress and depression could be improved if appropriate questions about suicide were more frequently asked by OH professionals, it concluded.
More than 60% of cases with distress were asked about family members, while a third were asked about alcohol, and 9% about drugs.
“A better understanding of potential barriers to recovery would be gained by asking about aspects of home and family life more often. Importantly, more consultations should include questions about alcohol and illicit drug use,” the audit added.
The audit also recommended that, for all staff on long-term sickness absence, regardless of their presenting problem, OH professionals needed to consider the possibility of depression.
“Where there is a suggestion of depressed mood, individuals should have a more thorough assessment of depression, including suicide risk. Additionally, many more cases should be asked about alcohol and drug use,” it recommended.
The audit showed evidence of constructive communication with line managers, with OH professionals generally being good at recording the contribution of workplace factors to any depression, and assessing whether to discuss this with the employer.
Another encouraging finding, said the OHCEU, was the high proportion of cases with depression who were asked about contact with other healthcare professionals.