NHS occupational health services in England and Wales--a changing picture

AIMS: To establish the extent of doctor input to occupational health (OH) service provision in the UK National Health Service (NHS) in 2001 and to compare this with inputs in 1998. METHOD: A postal questionnaire was used to obtain information from OH medical staff employed by the NHS in England and Wales. RESULTS: The NHS OH service has seen an increase between 1998 and 2001 in the amount of doctor time per employee. Doctors tend to work now for more sessions per week. The proportion of doctors holding specialist qualifications has also increased. An increased number of NHS employees now have access to consultant care for occupational medicine. OH departments increasingly tend to provide services to employees beyond the NHS and are thereby able to generate income to further the development of the service. CONCLUSIONS: Steady progress is being made in improving the provision of OH services within the NHS. However, substantial variation exists in the apparent level of access to such provision. The government policy for all NHS staff to have access to a consultant-led service is not yet met. NHS Plus will impact on this picture and deserves study in the future.     

An evaluation of occupational health services within the NHS in London

AIMS: To establish the nature, extent and organization of occupational health service provision for employees within the National Health Service (NHS) in London and to review the systems for monitoring performance. METHODS: Human resources directors and occupational health managers were contacted from a random selection of NHS trusts in the London area and invited to complete an interviewer-led questionnaire. RESULTS: All seventeen trusts interviewed claimed to provide an occupational health service to their employees, with 88% providing this service in-house. The organization of the services varied, although most resided within the human resources function. Only 29% of the trusts could provide a written occupational health policy. Teaching hospital trusts had the most qualified and the highest numbers of medical staff. District/General hospital trusts had the least qualified clinical staff. Although most trusts were able to provide a comprehensive range of services, 87% of occupational health managers felt they could only provide a reactive service. Income was generated from non-NHS sources by 88% of the trusts and all were aware of NHS Plus. There was an indication that some trusts assigned NHS Plus status did not meet the standard of NHS Plus, although the survey took place only 3 months after the launch of NHS Plus. CONCLUSIONS: There was a significant variation in the nature and extent of occupational health services in the NHS trusts. As a consequence, there may be differences in the level of occupational health service available to staff across the NHS in London.     

A survey of the delivery and uptake of influenza vaccine among health care workers

During the 1990s, policies for immunizing fit health care workers against influenza varied between National Health Service (NHS) employers and the uptake of influenza vaccine by NHS staff was poor. In light of recent Department of Health recommendations to immunize key health care staff against influenza, we explored the possible reasons for poor uptake and assessed the impact of an intensive promotion campaign on vaccine acceptance. Among 290 doctors and nurses, the main perceived barriers to influenza immunization were difficulty with practical access to vaccine and lack of time to attend. Following intensive promotion and improved local access to influenza vaccine, the uptake among health care workers was approximately doubled. However, the overall proportion of staff immunized was low (5%) and the immunization rate among medical staff was particularly poor (2%). The practical implications for influenza immunization campaigns aimed at health care workers are discussed.     

The involvement of occupational health services prior to ill-health retirement in NHS staff in Scotland and predictors of re-employment

OBJECTIVE: To assess the process, causes and outcomes of retirement because of ill-health in NHS staff in Scotland. Particular areas to be investigated include the involvement of occupational health services, access to rehabilitation and redeployment, current health, whether working again and to identify predictors of re-employment. METHOD: An ill-health retirement (IHR) questionnaire was mailed to 863 NHS staff awarded IHR benefits by the Scottish Public Pensions Agency between April 1998 and March 2000. RESULTS: In all, 49% of the 863 postal questionnaires were returned. The most common reasons for retiring were diseases of the musculoskeletal system (38%) and mental disorders (21%). Seventy-one percent of the participants reported their ill-health was partly or completely work related and 29% not work related. Ninety-two percent of NHS staff had attended an occupational health department prior to IHR. Twenty-three percent of participants had no contact with their line manager during their illness prior to retiral. Eighteen percent of individuals were offered the opportunity of working part-time and 15% offered alternative work. Seventeen percent of participants have obtained other work. Predictors of re-employment after IHR were: medical condition, managerial responsibility, improvement of health, wanting to work again, occupation and age at retirement. CONCLUSION: This is the first comprehensive study investigating NHS staff experiences of IHR in Scotland. This study illustrates the need for improved support and rehabilitation for ill-health care workers and that there is the potential to reduce levels of ill-health retirement.     

Charging for NHSPlus: an inferential study based on the internal provision of occupational health services within the National Health Service

BACKGROUND: 'NHSPlus' was conceived as a national agency that would provide occupational health services to organizations, for a fee, without imposing any financial burden on the taxpayer. This self-funding requirement brings into focus the resource implications for such a service and the determination of the charges to be made to external clients. AIM: The existing provision of occupational health services to >100000 National Health Service (NHS) staff by 13 NHS occupational health services of various sizes was analysed, with the objective of determining an appropriate charge-out rate to third parties. METHOD: Two focus groups were questioned on their work external to the NHS. Data collected on the allocation of doctors and nurses to occupational health services in relation to the number of NHS clients serviced were used to investigate the nature of the resourcing relationship using regression analysis. RESULTS: The relationship was found to be stable enough to provide a good estimate of staff requirements (the key resource requirement). Combining this with costing information allowed inferences to be drawn concerning the economic cost and hence the break-even rate of charge for the service. This was then compared with the employer charge rates in the NHSPlus published case studies. CONCLUSIONS: The results suggest that the per capita charges to external clients are lower than the per capita cost of internal occupational health provision within the NHS, raising questions about the viability of the service.     

Return to work after ill-health retirement in Scottish NHS staff and teachers

BACKGROUND: Most major public and private sector pension schemes have provision for ill-health retirement (IHR) for those who become too ill to continue to work before their normal retirement age. AIM: To compare the causes, process and outcomes of IHR in teachers and National Health Service (NHS) staff in Scotland. METHODS: A total of 537 teachers and 863 NHS staff who retired due to ill-health between April 1998 and March 2000 were mailed an IHR questionnaire by the Scottish Public Pensions Agency. RESULTS: The response rate for teachers was 53% and for NHS staff 49%. The most common cause of IHR was musculoskeletal disorders for NHS staff and mental disorders for teachers. Teachers retired at a younger average age than NHS staff. Ninety-two per cent of NHS staff but only 11% of teachers attended occupational health services (OHS) prior to IHR. Eighteen per cent of NHS staff and 9% of teachers were offered part-time work by their current employer in response to their ill-health. Fifteen per cent of NHS staff and 5% of teachers were offered alternative work prior to retirement. Seventeen per cent of NHS staff and 36% of teachers subsequently found employment. Multiple logistic regression analyses showed the following variables as independent predictors of subsequent employment: occupational group, age group, sex, managerial responsibility and cause of IHR. CONCLUSIONS: Return to work after IHR suggests that some IHR could be avoided. Teachers had a higher rate of return to work and much less access to OHS.     

National Services--the role of the National Services Division of the Common Services Agency in commissioning specialist services on behalf of the NHS in Scotland

The National Services Division of the Common Services Agency provides a central function commissioning designated national services on behalf of the NHS in Scotland. Services are nationally designated and commissioned only where it would not be possible or sensible to do so on a more local basis because of the rarity of the condition, the need to concentrate expertise and/or to avoid duplication of expensive equipment. The Division also has important central functions in ensuring the effective delivery of national screening programmes and in facilitating the development of national managed clinical networks. The work programme of the Division is overseen by advisory bodies whose membership reflects the key stakeholders in the Scottish NHS. In discharging its role, the Division's aim is to work with clinicians and managers to ensure the delivery of high quality specialist clinical care and screening services in an equitable fashion to patients throughout Scotland.     

Occupational Health Services in Manufacturing Industries in Nigeria

The provision of adequate health care facilities to cater forthe health of workers is an important consideration in the managementof manufacturing industries, since productivity is dependenton the health status of the workers. There are very few studiesevaluating the health care provision in Nigerian industries.This study elucidates such health care services in Edo and DeltaStates of Nigeria. One hundred and thirty-five (56%) of the241 registered manufacturing industries in Edo and Delta Statesof Nigeria were randomly selected and investigated. The responserate was 91.1% and the result showed that the medical staffcomprised 2.5% of the total workforce, with the large scaleindustries contributing the highest proportion of these. Fourpoint five per cent of the medical staff had formal trainingin occupational health and 15.6% of them visited the factoryshop floor. The doctor:staff ratio in the medium and large scaleindustries were 1:819 and 1:618 respectively. It was found thatall the industries used the health care facilities providedby the government, there were no clinics in all the small scaleindustries and group practice was not used by any of the industriesstudied. Pre-employment medical examinations were carried outin each of the groups of industries (100%, 39.4% and 5%) respectively,as were periodic medical examinations during employment, althoughto a lesser extent (100%, 13.2%, 0%) for the large, medium andsmall scale industries respectively. These finding suggest theavailability of a reasonable standard of health care provisionfor large scale industries and somewhat less availability formedium and small scale industries. Health education of boththe employers of labour, and the employees and the enforcementof existing laws are needed to improve the existing standardof occupational health services.     

Audit of immunization policy and practice of health care workers within National Health Service Trusts in England and Wales.

The purpose of this study was to identify the variation in occupational health immunization policies and practice within NHS Trusts throughout England and Wales. Questionnaires were sent to 440 NHS Trusts and 279 were returned (a response rate of 63%). The results were compared with current Department of Health Guidelines. They highlighted the fact that NHS Trusts do not adopt a consistent approach to immunization practice and that these policies often do not reflect Department of Health Guidance. Of those responding, 249 (89%) stated that they would like additional guidance on immunization practice within the NHS workplace. The production of updated, evidence-based guidelines for immunization practice, may help to ensure that a more consistent approach is taken throughout the NHS. This would benefit both the Trusts and their employees who at present may be confused by being given different advice when moving between Trusts.     

Factors influencing uptake of influenza vaccination among hospital-based health care workers

BACKGROUND: Vaccination of health care workers against influenza has been shown to lower mortality among elderly patients, but uptake of voluntary vaccination among health care workers remains low. AIMS: Factors influencing uptake of vaccination were examined among a cross-section of health care workers based in an NHS Trust. METHODS: A structured, self-administered questionnaire was mailed to a random sample of health care workers based in the acute services sector of a UK National Health Service Trust, 6 months following a voluntary immunization programme implemented as part of the Scottish Executive Health Department winter planning arrangements for 2000-2001. The programme was promoted using posters in clinical areas and a single leaflet given to all staff through a paycheck advice note. RESULTS: Five hundred and fifty-one health care workers (53%) responded to the questionnaire and influenza vaccination was accepted by 150 (28%). The occupational health poster strongly influenced the decision to accept vaccination [odds ratio (OR) = 11.01; 95% confidence interval (CI) = 2.13-56.80; P < 0.0001]. Other significant influences included female sex (OR = 9.11; 95% CI = 1.26-65.72) and perceived risk of contracting flu without the vaccine (OR = 7.70; 95% CI = 1.44-41.05). Misconceptions regarding the purpose of the vaccination campaign were common and concern regarding possible side-effects was a deterring factor for vaccination uptake. CONCLUSION: Our study showed that visual material displayed throughout the workplace strongly influenced the acceptance of influenza vaccination. Future campaigns should also emphasize the positive benefits to patients of health care worker immunization, with readily accessible information regarding side-effects available from all sources.     

Prevalence of measles susceptibility among health care workers in a UK hospital. Does the UK need to introduce a measles policy for its health care workers?

OBJECTIVES: First, to determine the prevalence of measles non-immunity in a group of health care workers (HCW), and secondly, to investigate what pre-employment screening for measles is carried out by NHS occupational health departments. METHODS: Two hundred and eighteen HCWs with patient contact on the medical wards at Addenbrooke's hospital provided an oral fluid sample and answered a questionnaire. A postal survey of Association of National Health Occupational Physicians Society (ANHOPS) members was conducted to assess whether UK NHS Trusts identify measles non-immune individuals. RESULTS: Of the HCWs tested, 3.3% of were found to be non-immune to measles (both oral fluid and confirmatory serum sample were measles IgG negative). Less than one third of a sample of 80 NHS occupational health departments enquired about measles immunity. CONCLUSION: The prevalence of measles non-immune health care workers is low, but with a fall in uptake of MMR immunization and increased likelihood of measles outbreaks, it is important to identify these at-risk individuals. Serum testing is the most reliable method to use. Oral fluid testing and history of measles disease or vaccination are unreliable methods of identifying non-immune individuals. To achieve complete immunity, it is cost-effective to screen and then offer immunization. NHS trusts vary greatly in their measles policies for health care workers.     

Incentives for voluntary HIV testing in NHS staff

BACKGROUND: HIV seroprevalence is rising in the United Kingdom. While acceptability of HIV testing has been explored among many groups there is a paucity of data regarding voluntary HIV counselling and testing (VCT) among NHS staff. AIMS: To understand the barriers to HIV testing among NHS employees. To observe how these may be overcome. To assess which factors would motivate staff to undergo VCT and which would be a disincentive. METHODS: Completion of a cross-sectional anonymous postal questionnaire survey of new employees at a London district general hospital. Demographic and attitudinal factors were collected. Respondents were able to give multiple responses to questions regarding reasons for and against VCT. Those unable to communicate in English were excluded. RESULTS: There was a 63% response rate; of 69 respondents, 76% were female, 72% had English as their first language and 30% self-identified as white British. Thirty-nine percent were nurses, 19% doctors and the remainder a variety of professions. Of these, 41% had had a previous HIV test; none were known positive. Sixty-two percent would consider future testing. The commonest reasons to consider testing were knowledge of status (79%), treatment benefit (40%) and to inform family members (44%). The commonest reasons not to test were already tested negative (30%) and rather not know (26%). CONCLUSIONS: Since the NHS is recruiting staff from areas of high HIV prevalence, VCT should be encouraged. NHS staff require information on how to access testing as well as the benefits of early detection of blood-borne viruses.     

Implementation of Department of Health guidelines for hepatitis B vaccination: a regional audit of NHS occupational health policies and procedures

The objective of this study was to assess the implementationof the UK Health Departments' guidelines on protecting healthcareworkers and patients from hepatitis B infection. The surveytook place in February 1994 in the form of a postal questionnairesurvey of occupational health departments. The study frame wasthe 18 district-based occupational health departments in thenorthern region of the NHS. The main outcome measures were compliancewith the national guidelines on vaccination and the assessmentof the hepatitis B status of employees performing exposure proneprocedures. Compliance with the guidelines was variable. Therewere marked variations in the interpretation of serologicaldata and there was a failure to establish the hepatitis B statusof surgeons, in some cases. There is a need to provide trainingfor occupational health practitioners about hepatitis B andto ensure that there is a uniform standard of practice withinthe NHS.     

Management of hepatitis B immunizations and blood exposure incidents in primary care

AIM: To investigate how well primary care health care workers, with no access to an occupational health service (OHS), have managed their hepatitis B immunizations and blood exposure incidents, compared with National Health Service Trust staff, with access to an OHS. METHOD: A questionnaire was sent to 78 general practitioners (GPs), 93 general practice nurses, 81 NHS Trust consultants and 88 NHS Trust community nurses, in the Airedale area of West Yorkshire in June 2001. RESULTS: The response rate was 80%. GPs were significantly less likely than consultants to have received a hepatitis B booster vaccination after their primary course (57 versus 80%, P < 0.009) and significantly less likely to have had their blood anti-HBs test checked after their last vaccination (74 versus 94%, P < 0.011). General practice nurses were significantly less likely to fill in a blood exposure incident form after an injury than community nurses (56 versus 91%, P < 0.006). Overall, the group with access to an OHS was significantly more likely to have received a hepatitis B booster (P < 0.036), have had a blood anti-HBs test after last vaccination (P < 0.010) and to have filled in a blood exposure incident form after last blood exposure (P < 0.033), than the group without access to an OHS. CONCLUSION: Any future OHS with responsibility for primary care, should consider calling in all GPs and general practice nurses for a review of their hepatitis immunity and for education regarding the management of blood exposure incidents.     

Perceptions of community leaders and the merger of rural health services

The merger of rural primary care and home health services offers the potential of increasing the administrative efficiency of health care, and thereby enhancing quality of care and increasing access to services, particularly health promotion. In a merger of rural health services in Northeastern Vermont, a survey of key community leaders revealed that improved organization of services, improved health status and greater accessibility of services were benefits expected and to some extent realized as a result of the merger process. The desire to preserve community-based services and having a common philosophy were important factors which served to initiate the merger. The actions of a few key individuals and the support of involved organizations were instrumental in continuing the process.Dr. Smith is an Assistant Professor, Department of Health Services Management and Policy, The University of Michigan School of Public Health.Dr. Zuckerman is an Associate Professor, Department of Health Services Management and Policy, The University of Michigan School of Public Health.This study was supported by a grant from the W.K. Kellogg Foundation (UHG0001L/RAD).     

Provider arrangements for mental health services in 'The New NHS'

Mental health services in England, in common with many other European countries, have been the subject of sustained government attention during the 1990s. Since the election of the Labour administration in Britain in May 1997, mental health services have been discussed in most Department of Health documents on health and social care policy, and mental health services in England have a new national strategy. At the same time, the local provision of mental health services within NHS Trusts has been undergoing organisational change. This paper sets out the policy context and evidence base for the reorganisation of provider arrangements for mental health services. In addition, the results of a documentary analysis of unpublished reviews of provider arrangements in 10 localities are presented. The review identified three major themes: firstly, the reconfiguration of NHS Trusts is based around Specialist Mental Health Trusts and Community and Mental Health Trusts; secondly, the joint provision of services and/or the integration of services between health and social services is starting to appear and; thirdly, the delegation of responsibility to localities based on Primary Care Group/Social Services boundaries is being discussed. The paper discerns a number of trends and points to the need for further research, in particular into the relationship between organisational arrangements and effective service delivery.     

Long-term sickness absence in an NHS teaching hospital

This study was carried out to investigate the incidence andcauses of long-term sickness absence in an NHS teaching hospitaland to explore the role of the Occupational Health Service (OHS)in the management of long-term absence. Examination of attendancerecords of non-medical staff revealed an annual loss of 20,772days due to spells of absence lasting 30 calendar days or more,(incidence 0.0528/WTE employees/year, prevalence 5.53 days long-termabsence/WTE employee/year). A self-administered questionnairewas sent to 190 staff who had taken long-term absence duringthe previous 12 months. The response rate was 75%. Musculoskeletalproblems and back pain in particular were the main reasons forabsence, accounting for 30% of total days lost. Work-relatedillness made an important contribution with a third of thosewith musculoskeletal and a quarter of those with mental illnessattributing the reason for their absence to work. Many staffreported non-medical factors such as delays in waiting for treatmentand anxiety about return to work which prevented them from returningto work sooner. Only a minority of staff had attended OHS andreferral was often delayed. OHS may have an important role toplay in both prevention and management of long-term absenceby early assessment and intervention such as expediting treatmentor arranging rehabilitation programmes. However in order tobe effective, a clear policy to encourage early and consistentreferral is required.     

Exploring the need for an occupational health service for those working in primary care

A research nurse interviewed 55 practice staff in 11 generalpractices to ascertain their views about their needs for occupationalhealth care. In a second parallel study, a specialist in occupationalmedicine undertook an in-depth audit of occupational healthprovision in five other general practices with respect to theorganization, the health and safety process, the services andthe working environment. In the first study, the majority ofpractice staff reported the need for various aspects of occupationalhealth care, particularly stress at work. In the second study,general practitioners and practice managers possessed a basicawareness of occupational health matters such as Health andSafety legislation, but their limited knowledge was not translatedinto effective management. General practice staff did not knowwhere to obtain occupational health advice; most practices hadno policies or procedures in place to manage health and safety.Both studies illustrate the need for expert occupational healthadvice in primary care.     

Hepatitis B--are surgeons putting patients at risk?

The 1993 Department of Health guidelines permit a surgeon who is hepatitis B surface antigen (HBsAg) positive but e-antigen (HBeAg) negative to perform exposure prone procedures, unless demonstrated to have infected patients. However, there is increasing evidence of transmission of hepatitis B to patients from health care workers in this supposedly low infectivity category. The Occupational Physician must decide whether existing guidelines represent an adequate risk assessment and indeed whether this is an acceptable risk for patients. If an NHS Trust continues to follow these guidelines it may be in breach of its duty of care to patients. Yet refusing to allow such carriers to operate without testing for additional serological markers may be unlawful discrimination. Further research is clearly needed as well as an urgent review of the guidelines.     

Reported needlestick and sharp injuries among health care workers in a Greek general hospital

Between July 1990 and June 1996, 284 exposures to infectious material were reported by 247 health care workers (HCWs) at AHEPA University Hospital, Thessaloniki, Greece, representing an overall rate of 2.4% reported injuries per 100 HCWs/year. Nurses reported the highest rates of incidents (3.0%) and in all but one working group women exhibited higher injury rates per year than male HCWs. Young workers (21-30 years old) were primarily affected in incidents (P < 0.001). Needles were the most common implement causing injury (60.6%) and resheathing of used needles as well as garbage collection were common causes of injury. None of the HCWs seroconverted in exposures where immune status to blood-borne pathogens was estimated. Efforts by the infection control committee need to be more intense, in order to increase the rate of reported staff injuries. This will facilitate identification of unsafe practices and provide more adequate preventive measures.