Despite the fact that GPs are on the front line of NHS services, awareness of OH or health and safety practices has not in the past been high, and the service still awaits the arrival of a national OH service. This is despite high-profile cases of GPs suffering addiction to substance abuse and suffering from stress-related problems. The arrival of primary care trusts (PCT) could bring more focus to this problem.
The experience of OH practitioners in the Midlands demonstrates how awareness can be raised, and examples of good practice in delivering OH services to GP practices and measuring their benefits. This account shares some of the lessons learned in the process, as well as directing readers to the documents that offer a framework for developing GP services.
Occupational health and safety services to Sandwell GPs began in 1998, and established the first such service within England and Wales.
Initially, one OH adviser was appointed to develop and deliver OH and health and safety services to 69 GP surgeries and 42 dental practices, with a total employee population of approximately 2,000 people. Funding was based upon the Chambers blueprint model,1 which calculated a figure of 200 for each lead GP within the practice.
The initial stages of the project involved drafting and distributing publicity, and the active promotion of health and safety assessments as a means of gaining access to practice premises. Efforts were also made to identify key individuals and organisations. This led to meetings with local medical and dental committees, where agreement was reached about the likely nature of the proposed service and its operation.
The OH adviser attended practice manager forums in each of the primary care group areas as a means to inform and recruit further practices to the service. As a result, 50% of the GPs within Sandwell accepted the service. Practice managers were specifically targeted as it was assumed that they, as senior managers, would deal with the majority of health and safety and personnel issues arising in the various practices.2
In the early stages of service development, a pilot of the service process and a needs assessment was undertaken in order that the service should most closely match the needs of its customer base.
Health and safety issues were thought to be a good starting point, as the literature demonstrated that few GP practices have a coherent system for dealing with health and safety issues in place.2,3,4,5,6
Leading with health and safety issues gave the OH adviser entre to individual practices and allowed him also to discuss specific OH needs within each workplace. The pilot needs’ assessment confirmed the view that few practices had made provision for dealing with health and safety needs in a systematic way. Such provision, as did exist within the pilot practices, tended to be piecemeal. Where health and safety policies existed, few had been fully implemented.
The findings of the pilot needs’ assessment are mirrored in the findings of those studies of health and safety compliance and OH provision within the UK.2,3,4,5,6
A number of public health policy documents have focused on the need for partnership working as a way of delivering such services,7,8,9 so from the outset, the Sandwell service adopted a partnership approach.
As a result, the OH adviser sought active participation from senior line managers, HR, clinical governance, infection control, public health and counselling services for discussions surrounding service delivery and referral mechanisms. Collaboration was also established between the GP service and the Workwell Initiative, which offers workplace health and safety support to SMEs in the Midlands.
The needs of GPs and their staff have been recognised in a specific public health document, The Provision of Occupational Health and Safety Services for General Medical Practitioners and their staff. This both offers various models – including the Sandwell model – for adoption in service delivery and suggests that a partnership approach be taken in the provision of such services.9
Within the general literature, few studies, to date, have addressed the level of awareness of OH and health and safety issues within general practices in the UK.
A search of various electronic databases, including Medline, Cinahal and Psychinfo, produced only five papers that specifically examined these issues.2,3,4,5,6
These studies found that the majority of practices had not implemented any of the few health and safety policies that they had developed, and that only a handful of practices had a coherent and systematic approach in dealing with either health and safety or OH issues.
Yet of the GP practices described in previous studies, the majority had little difficulty in identifying the OH needs of their staff. OH needs cited included: mental illness, stress and stress interventions, sickness absence support and advice, substance abuse, workload and patient violence and aggression.2,3,4,5,6
Chambers offers a useful summary of the likely requirements of an OH and health and safety service for GPs. The requirements included: expert advice, the provision of model health and safety policies, and a range of proactive/reactive services, which would facilitate compliance with health and safety legislation and improve the health and well-being of practice staff.1
In Harrison’s study of 134 GP practices in Tyneside,2 the majority of GPs surveyed felt that any specialist provider supplying OH or health and safety advice should, in particular, have an understanding of both the NHS and the work of GPs specifically. With the exception of Sheikh,5 none of the authors examine specific health problems experienced by the wider community of general practice staff. It was also noted that, although they make general recommendations, none of the authors actually set out a model for service delivery/service process.
A number of factors within the last year have led to developments within the service and its subsequent re-design.
The first of these was the award of two new contracts for provision of services to GP practices within the heart of Birmingham and Walsall PCTs. This generated extra funds and allowed the recruitment of a further OH adviser and a dedicated health and safety officer. So, the opportunity arose to re-orientate the service using the varied experience of the two new members of staff. The intent at the outset was to utilise the lessons already learned and capitalise on the wider experience of the group.
Following on from our earlier findings, it was felt that the ideal outcome should be a behavioural change among GPs in relation to health and safety practice and the use of OH services. The aim was to create an initiative for change, which would lead the safety culture in each practice forward.
Haney and Anderson outline such an initiative under the following headings: identify health and safety improvement areas, determine safe behaviours, observe and record behaviours, set goals for improvement, measure and record data, offer feedback and reinforce good safety/health behaviour.11 This approach was incorporated into the redesign of the service process and the tools used to deliver the service.
Redesigned service process
From the outset, a service process was established to ensure continuity and maintain efficiency. The service itself had been well received and feedback from clients was positive.
However, in retrospect, the initial service process and the concurrent writing of detailed reports proved to be extremely time consuming.
In addition, while it could be confidently stated that the profile of both health and safety and OH had been raised in those practices that had been visited, it was rather more difficult to measure and demonstrate tangible improvements in health and safety compliance within individual practices.
Redesigning the service began with the development of two assessment tools: one for baseline health and safety assessment and the other for OH needs’ assessment. Both assessment tools can be used in either GP surgeries or dental surgeries.
The health and safety assessment tool was based on the advice set out in the Health & Safety Executive’s (HSE) document Successful health and safety management.10 Advice is offered to individual practices based on the outcome of this baseline health and safety assessment, and a percentage score is awarded, which acts as a benchmark for subsequent review visits.
The OH needs’ assessment tool was designed to both compliment the health and safety tool and reflect the needs expressed both in the literature,2,3,4,5,6 and in the findings of the pilot exercise.
The combined OH and health and safety visit schedule is outlined in the table on page 19.
The assessment process has been automated via a database designed in-house. This allows production of individual reports shortly after the baseline visit for subsequent discussion at the first review. Therefore, first reviews focus on specific improvements and goal setting for the second review visit. At the second review, long-term aims and objectives are set for consideration at an annual visit. In subsequent years, further baseline assessments will be carried out to audit and review current performance against that previously achieved.
The developing service
A fully-rounded and independent service for GPs and their staff can be provided where services generate enough income to provide both dedicated OH and health and safety advice to individual practices. Cross Trust services, working in partnership, offer sufficient momentum for future development and the incorporation of new ideas.
From the outset, the GPD service has offered a wide range of core and additional services. These are set out below.
- Pre-employment screening
- Vision screening
- Sickness absence management
- Management referral
- Advice on rehabilitation and redeployment
- Base and practice-held clinics
- Health and safety advice
- Health and safety assessments
- Telephone support helpline
- Stress management courses
- Assistance with occupational health and safety planning
- Health and safety policy development
- Risk assessment training.
A number of future developments are also currently underway or in the process of planning. The first of these is the creation of a training plan to be implemented over the next 12 months. This will involve building a suite of courses aimed at meeting the needs of individual practices. The courses will be developed both in-house and in partnership with the private sector.
The service also plans to use the expertise of an ergonomist to provide awareness sessions and offer individual ergonomic assessments to practices on request. Negotiations are also underway with a private provider to pilot health and fitness provision linked to physiotherapy for GP and dental practices.
Finally, the service looks forward to regional expansion and possible integration into a form of national OH service provision, as outlined in the OHAC report published in 2000.8
David Riley is senior OH nurse and GPD service manager, and John Lehane is OH adviser at the Sandwell and West Birmingham Hospitals NHS Trust
1. Chambers, R. Occupational health services for GPs – a national model. Royal College of General Practitioners/General Medical Services Committee. London:RCGP 1997
2. Harrison, J and Harrison, CE. Developing a model for occupational health provision in primary care. International Journal of Occupational Medicine and Environmental Health, Vol 15 No 2 2002 pp 185- 192
3. Chambers, R, Miller, D, Tweed, P, and Campbell, I. Exploring the need for an occupational health service for those working in primary care. Occupational Medicine Vol 47 No 8 1997 pp 485-490
4. Chambers, R, George, V, McNeill, A, and Campbell, I. Health at work in the general practice. British Journal of General Practice Vol 48 1998 pp 1501-1504
5. Sheikh, A and Hurwitz, B. Psychological morbidity in general practice managers: a descriptive and explanatory study. British Journal of General Practice (2000) Vol 50 March
6. Kennedy, I, Williams, S, Reynolds, A, Cockcroft, A, Solomon, J, and Farrow, S. GPs compliance with health and safety legislation and their occupational health needs in one London health authority. British Journal of General Practice. Vol 52 2002, pp 741-742.
7. Securing Health Together. Health & Safety Commission (2000) HSE Books London
8. Occupational health advisory committee: report and recommendation on improving access to occupational health support. Health & Safety Commission (2000)
9. The Provision of Occupational Health and Safety Services for General Medical Practitioners and their staff. Department of Health (2001) HMSO
10. Successful health and safety management (HSG65) HMSO/HSE/HSC
11. Haney, L and Anderson, M. Behaviour based safety: A different way of looking at an old problem. AAOHN Journal Vol 47 No 9 September 1999 pp 424-435
SCHEDULE OF GP PRACTICE VISITS TO DEVELOP OH SERVICES
Occupational health/Health and Activity Expected
safety combined visit schedule
1. Baseline assessment of H&S assessment: Raise awareness,
current health and safety (H&S) Walk-round identify needs.
practice assessment Following assessment
practice given % score
2.First H&S review visit two Present assessment Set goals for second
weeks from baseline visit report and discuss review visit
goals and targets
3. Occupational health needs’ OH needs’ assessment Raise awareness and
assessment visit six weeks tool used. Supply OH identify needs.
from initial visit handbook. Provide Generate satellite OH
forms Immunisation clinics
DSE Screening clinics
4. Second H&S review visit eight Review set goals and 1. Signed
weeks from baseline visit discuss longer-term H&S policy in place
development over 2. Delegation of H&S
next nine months responsibilities
3. Undertaking risk
4. Long-term targets set
5. Annual review visit one year Reapply assessment Demonstrable
from initial visit tool. Review targets improvement via
increased percentage scorecome