Consultant and Senior Lecturer in Occupational Medicine, Guy s and St Thomas NHS Foundation Trust, London, UK 7

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1 Journal of Evaluation in Clinical Practice ISSN Measuring how well the NHS looks after its own staff: methodology of the first national clinical audits of occupational health services in the NHSjep_ Siân Williams MBBS MRCP MD FFOM, 1 Caroline Rogers BSc (Hons) MRes MSc, 2 Penny Peel BSc MSc, 3 Samuel B. Harvey MBBS DCH MRCGP MRCPsych, 4 Max Henderson MBBS MSc MRCP MRCPsych, 5 Ira Madan MBBS (Hons) FRCP FFOM, 6 Julia Smedley BMedSci (Hons) MBBS MD FFOM FRCP 7 and Robert Grant BSc DipStat MSc 8 1 Clinical Director, 3 Programme Manager, Health and Work Development Unit, Royal College of Physicians, London, UK 2 Programme Manager, Nuffield Council on Bioethics, London, UK 4 Clinical Lecturer and Honorary SpR in Psychiatry, 5 Senior Lecturer in Epidemiological & Occupational Psychiatry and Honorary Consultant Liaison Psychiatrist, Institute of Psychiatry, King s College London, London, UK 6 Consultant and Senior Lecturer in Occupational Medicine, Guy s and St Thomas NHS Foundation Trust, London, UK 7 Consultant and Senior Lecturer in Occupational Medicine, Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton, UK 8 Medical Statistician, Royal College of Physicians, London, UK Keywords clinical audit, methodology, national audit, National Health Service, occupational health Correspondence Dr Siân Williams Health and Work Development Unit Royal College of Physicians 11 St Andrews Place Regents Park London NW1 4LE UK sian.williams@rcplondon.ac.uk Further details about the audits and the results of this paper can be found in: Occupational Health Clinical Effectiveness Unit. Depression screening and management of staff on long-term sickness absence Occupational health practice in the NHS in England: A national clinical audit. London: RCP, Occupational Health Clinical Effectiveness Unit. Back pain management Occupational health practice in the NHS in England: A national clinical audit. London: RCP, Accepted for publication: 5 August 2010 Abstract Rationale, aims and objectives Little is known about the quality of occupational health care provided to National Health Service (NHS) staff. We designed the first national clinical audits of occupational health care in England. We chose to audit depression and back pain as health care workers have high levels of both conditions compared with other employment sectors. The aim of the audits was to drive up quality of care for staff with these conditions. The object of this paper is to describe how we developed an audit methodology and overcame challenges presented by the organization and delivery of occupational health care for NHS staff. Methods We designed two retrospective case note audits which ran simultaneously. Sites submitted up to 40 cases for each audit. We used duplicate case entry to test inter-rater reliability and performed selection bias checks. Participants received their site s audit results, benchmarked against the national average, within 4 months of the end of the data entry period. We used electronic voting at a results dissemination conference to inform implementation activities. Results Occupational Health departments providing services to 278 (83%) trusts in England participated in one or both audits. Median kappa scores were above 0.7 for both pilot and full audits, indicating good levels of inter-rater reliability. In total, 79% of participants at a dissemination conference said that they had changed their clinical practice either during data collection (52%) or following receipt of their audit results (27%). Conclusions Clinical audit can be conducted successfully in the occupational health setting. We obtained meaningful data that have stimulated local and national quality improvement activities. Our methodology would be transferable to occupational health settings outside the NHS and in other countries. doi: /j x Introduction National clinical audit methodology is well established in the UK. It has been successful at measuring, and driving up, standards of care in several medical specialties [1,2]. In this paper we describe the design of the first ever national clinical audits of occupational health (OH) care for National Health Service (NHS) staff in England. Some of the methodology builds on that used in the more 2010 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 18 (2012)

2 Occupational health audit methodology S. Williams et al. established clinical specialties, such as stroke [3], and some we developed specifically to address the complexities of OH service design and case management. The NHS in England is the largest employer in Europe with approximately 1.4 million staff looking after a population of 56 million. English health care professionals report more workrelated health problems than most other professional groups [4 7]. The NHS has high levels of health-related work impairment (presenteeism), high rates of sickness absence and extensive numbers of staff claiming long-term incapacity benefits [6 9]. NHS employees take on average 10.7 days of sick leave per annum, compared to 9.7 days in the rest of the UK public sector and 6.4 days amongst UK private sector employees [6]. The most common apparent causes are psychiatric disorders and musculoskeletal problems [6,9]. Studies of NHS acute trusts have shown associations between staff ill health and low patient satisfaction, high rates of hospital acquired infections and poorer overall performance [6,10,11]. To support the health of its staff the NHS provides OH services. Each NHS trust is responsible for either employing its own inhouse OH team or commissioning services from an external provider. OH service provision varies across the country in terms of staff numbers, type, qualifications, services offered and funding level. Advising staff and their managers on health problems that are caused or made worse by work, and the impact of health problems on capacity for work, is an important core OH service activity. To drive up quality of care we designed two national clinical audits of OH care in the NHS in England. We chose to audit back pain management, and the detection of depression in staff on long-term sickness absence. These conditions were chosen because they are common, account for a high proportion of sickness absence, and both have national evidence-based guidance from which to develop audit criteria [12,13]. The main aims of our audit projects were to: develop a methodology for national clinical audit of OH practice; assess variation in practice amongst OH clinicians providing services to NHS staff in England; benchmark current practice, both locally and nationally, against guideline standards; and provide baseline data for further quality improvement activities. We describe here how we developed a methodology and overcame potential problems through the process of audit design, execution, data analysis, reporting and follow-up work with audit participants and their trusts. We present results on participation, selection bias, inter-rater reliability, typographic errors, data completeness, uptake of dissemination activities, and qualitative feedback from participants. Methods The team The audits were run by the Occupational Health Clinical Effectiveness Unit (OHCEU). This collaboration between the Royal College of Physicians of London and the Faculty of Occupational Medicine was commissioned and funded by NHS Plus [14,15], with the aim of raising standards of OH care in the NHS and more widely. Senior clinicians led on the audit design and development of the data collection tool, and were supported by a multidisciplinary audit development group. The OHCEU steering group, consisting of the key stakeholders, agreed the final audit process and reports. Recruitment of participants The organization of OH services within the NHS in England is complex. There are fewer OH providers to the NHS than there are NHS trusts. Many trusts with an in-house OH service deliver a service to several other local trusts under contract, and a few trusts use more than one OH provider. In addition, some commercial OH providers service several trusts across very wide geographical areas. We issued a unique identifying number to each pairing of a trust and OH service. We refer to these pairings as sites and each site was asked to submit a separate set of case notes to the audit. All NHS trusts in England were invited to participate through letters to their human resources directors, clinical audit departments, chief executives and OH providers. The audits were also advertised through professional journals, newsletters, mail shots and a free national conference for potential participants. Throughout the data entry period further reminders were sent to OH departments using and posted letters. Non-participants were contacted by the OHCEU audit team and OH champions at regional level, aiming to address any barriers to participation. Audit design and timeline The two audits ran simultaneously. Both were retrospective case note audits. For each one, participating sites were asked to identify the case notes of 40 consecutive staff who attended their OH department between January and May 2008 and fulfilled the case definition shown in Box 1. Data were extracted from the case notes and entered locally in May, June and July Local results were sent to participating sites electronically in December 2008 and national results were published in January We held a national dissemination conference in April 2009 and regional implementation workshops in June and July August 2009 (see Fig. 1). Development of audit questions and tools For each audit, the questions reflected recommendations in relevant national evidence-based guidance [12,13] plus questions proposed by the audit clinical leads in consultation with the audit development group. A web-based data collection tool was created using the techniques developed by the Royal College of Physicians Clinical Effectiveness and Evaluation Unit in audit topics such as stroke and evidence-based prescribing [16]. The web tool routed the data collector through a series of questions for each set of case notes that was audited, making available only the applicable answers. Responses were checked by the computer against pre-defined rules to avoid errors. The web tool allowed free text comments to be appended to each response. No patient-identifiable data were requested. The pilot We piloted both online audit tools in March Eight sites volunteered to participate. All were acute trusts but differed in size Blackwell Publishing Ltd

3 S. Williams et al. Occupational health audit methodology Box 1 Inclusion criteria for audit cases Depression screening and management during long-term sickness absence A National Health Service staff member s first consultation, between 1 January 2008 and 22 August 2008, with an occupational health doctor or nurse following 4 weeks of sickness absence for any health-related reason. Back pain A National Health Service staff member s first consultation for a new episode of back pain (separated from any previous episode by at least 4 weeks) with an occupational health doctor or nurse between 1 January 2008 and 25 July We did not include consultations with physiotherapists in this audit as these would need to be audited against other guidelines. Participants were asked to submit a sample of 40 consecutive eligible consultations for each audit. Audit Delivery Timeline Data collection and analysis Dissemination and implementation Data collection begins Report writing ends Local results sent National conference for audit result dissemination Regional workshop programme ends 2008 Jan May Aug Dec 2009 Jan Apr Jun Jul Site recruitment and case selection begins Data collection finishes Statistical analysis and report writing begins National results published Regional implementation workshop programme begins Figure 1 Audit timeline. and geographical location. Data from the pilot were analysed for completeness, coherence, and reliability. Participants were asked about any difficulties in using the questionnaire/web tool, retrieving relevant information or interpreting the questions. Results from these data were examined by the project team and refinements made to the audit questions and the supporting help notes for participants. Full data collection Once a participating trust had registered its details and its OH provider s details, a unique username and password were issued to allow confidential electronic data entry. The web site was open for data collection for 3 months and the OHCEU provided a helpdesk throughout this period to answer queries from participants. Responses to common queries were circulated amongst all participants to improve accuracy of sampling, data extraction and entry. OHCEU was able to interrogate the web tool for information on individual sites activity, so that reminders could be tailored appropriately. Patient confidentiality Data extraction for national clinical audit is usually supported by trust audit department staff locally. However, as OH patients are staff of these trusts, we recommended that only OH doctors or nurses extracted the data (but where possible did not enter data from their own case note entries). After the close of data collection, data were transported from the web tool and held securely at the OHCEU where they were cleaned and analysed by the project team. Inter-rater reliability We used inter-rater reliability checks to test the extent to which different auditors would collect the same data about a given patient. Misunderstanding of the questions, errors in using the web tool, typographic errors and ambiguity in the case notes can all lead to disagreements. We assessed inter-rater reliability quantitatively for the pilot study and again for the main data collection period. For each sample submitted to the audit, the first five cases were re-entered by a second, independent data collector. We calculated Cohen s kappa scores for questions with binary data, and percentage agreement for numerical data. The McNemar Bowker test was used to consider whether there was a systematic difference between earlier and later entries of the same data that might reflect availability of information to the auditors. We also compared the cases submitted with duplicates to those submitted without duplication in terms of demographics and 2010 Blackwell Publishing Ltd 285

4 Occupational health audit methodology S. Williams et al. length of time off work (which we regard as a proxy for the complexity of the patient s OH notes) to make sure there was no selection bias. Selection bias checks Within each audit we checked for selection bias in those sites submitting fewer cases; this can occur inadvertently if simpler or more accessible sets of case notes are entered first but the auditor then omits to complete the remainder. We compared data from sites that submitted fewer than the median number of cases with data from those submitting more in terms of age, gender, occupation, whether the person had been off work (in the back pain audit only) and how long they had been off work. When assessing selection bias, we did not conduct statistical tests of significance because we are not able to distinguish sites that chose to enter few cases from those that only had very few and could not have entered more; selection bias is only a real concern for the former group. Also, there may be unknown characteristics of the site and the OH service which confound the association between having few data entered and demographics or time off work, and we are not in a position to adjust for these. A third consideration is that the great majority of OH services are represented in the data and so inference to a population of sites is not meaningful. Reporting results to providers and commissioners of services Site level results were confidential and were provided only to the OH service and trust to which they related for comparison with the national average results. Trusts that had entered a small number of cases were warned to consider their own results from the audit with great caution, but were reassured that they still contributed usefully to the national statistics. Because only the local OH team will fully understand the context of the service organization, inference was not made in the report in the form of confidence intervals or hypothesis tests. National conference for audit participants We held a national audit dissemination conference 4 months after participants received their audit reports. We used anonymous electronic voting to explore participants attitudes, behaviour and needs around depression screening and back pain management. Regional quality improvement workshops We held nine regional workshops across England 6 months after attendees had received their audit results. Working in small groups, participants used an adapted template developed by the National Institute for Health and Clinical Excellence [17] to explore barriers experienced locally in implementing guideline recommendations and to design action plans. We identified common themes from the completed templates and sent these to audit participants to further inform their quality improvement activities. Results Pilot of the questionnaire Seven of the eight volunteer sites piloted at least one of the audit tools. For the back pain audit, six sites recorded 27 sets of patient notes with second auditors duplicating 12 of these. For depression screening, seven sites audited 48 sets of notes and duplicated 18 of these. Kappa scores summarizing the inter-rater reliability had median 0.78 in each audit but covered a wide range with 8/31 back pain questions scoring below 0.6 and 2/31 below 0.4. In the depression screening data, 7/26 questions scored below 0.6 and 2/26 below 0.4. Minor changes were only made to a few questions, based on kappa results and feedback from pilot sites. Data cleaning The web-tool design produced consistent and valid data that required very little cleaning. In the free-text field of the data tool 1616 comments were entered for the back pain data and 1051 for the depression screening. Most of the comments did not influence data analysis. In a few cases the participant explained that the web tool had required completion of a field despite the answer being unknown. In these cases the response was deleted. Response rate The back pain audit collected 2959 cases from 261 sites. These sites provided services to 253/389 (65%) NHS trusts. Many sites were unable to identify 40 eligible cases, with only 117 (46%) sites submitting 10 or more cases. A similar pattern was seen in the depression screening audit although total numbers were higher; 6286 cases were audited by 277 sites. These provided services to 267/389 (69%) trusts. A total of 219 sites (79%) submitted 10 or more cases. The OH departments providing services to 83% (278/389) of NHS trusts in England participated in one or both of the audits. Selection bias checks When we compared data from sites submitting fewer than the median number of cases with those submitting more within each audit, we found no persistent differences of a size that might suggest bias in case selection in terms of age, gender, occupation or time off work (Table 1). For the depression screening audit, participants were asked to include staff seen after 4 weeks of sickness absence for any health problem. However, 9% of sites (26/277) entered only patients with a psychological diagnosis, accounting for 3% (186/6286) of cases entered nationally. In total, 4% of sites (11/277) entered only patients diagnosed with depression. For the back pain audit, participants were asked to include all new cases of back pain seen in OH, whether at work or off sick. However, 31% of sites (81/261) entered only patients who had been off work with back pain. These accounted for 13% (372/ 2959) of cases. Data from these sites were compared to the others in terms of time off work (as a proxy for severity), and no system Blackwell Publishing Ltd

5 S. Williams et al. Occupational health audit methodology Table 1 Checks for selection bias in sites selecting fewer cases Back pain Depression screening From sites submitting fewer than median cases (1 8) From sites submitting more than median cases (>8) From sites submitting fewer than median cases (1 20) From sites submitting more than median cases (>20) Age (years) < (35%) 932 (38%) 408 (26%) 1379 (29%) (49%) 1217 (50%) 879 (55%) 2504 (53%) >55 89 (17%) 361 (12%) 299 (19%) 817 (17%) Gender Male 105 (20%) 423 (17%) 266 (17%) 746 (16%) Female 433 (80%) 1998 (83%) 1320 (83%) 3954 (84%) Occupation Allied 65 (12%) 324 (13%) 212 (13%) 536 (11%) Ancillary 110 (20%) 406 (17%) 284 (18%) 859 (18%) Clerical 69 (13%) 323 (13%) 288 (18%) 731 (16%) Doctor 5 (0.9%) 48 (2%) 28 (2%) 87 (2%) Nurse 265 (49%) 1140 (47%) 675 (43%) 2157 (46%) Other 24 (4%) 173 (7%) 95 (6%) 313 (7%) Off work? 424 (79%) 1615 (67%) Not applicable Not applicable Weeks off work Median 5 weeks 4 weeks 9 weeks 9 weeks IQR 3 10 weeks 2 8 weeks 6 16 weeks 6 14 weeks IQR, inter-quartile range. Table 2 Checks for selection bias in inter-rater reliability duplicates Back pain Depression screening Not duplicated Duplicated Not duplicated Duplicated Age (years) < (38%) 252 (37%) 1563 (29%) 224 (26%) (50%) 348 (51%) 2919 (54%) 464 (54%) > (12%) 87 (13%) 951 (18%) 165 (19%) Gender Male 400 (18%) 128 (19%) 873 (16%) 139 (16%) Female 1872 (82%) 559 (81%) 4560 (84%) 714 (84%) Occupation Allied 318 (14%) 71 (10%) 643 (12%) 105 (12%) Ancillary 404 (18%) 112 (16%) 1016 (19%) 127 (15%) Clerical 304 (13%) 88 (13%) 873 (16%) 146 (17%) Doctor 34 (2%) 19 (3%) 103 (2%) 12 (1%) Nurse 1053 (46%) 352 (51%) 2434 (45%) 398 (47%) Other 153 (7%) 44 (6%) 347 (6%) 61 (7%) Off work? 1545 (68%) 494 (72%) Not applicable Not applicable Weeks off work Median 4 weeks 4 weeks 9 weeks 9 weeks IQR 2 8 weeks 2 8 weeks 6 14 weeks 6 15 weeks IQR, inter-quartile range. atic difference was seen. The possibility of cross-confounding between patients and site-level characteristics makes it unwise to do significance testing. Inter-rater reliability In addition to the data collected for the main audit analyses, 697 cases from the back pain audit and 864 cases from depression screening had been independently re-audited and entered into the web tool by the second auditor. These were checked for accidental triplicates and the numbers reduced to 685 and 853. Cases selected for duplicate entry were not noticeably different to those not selected in terms of demographics or the complexity of their notes, as measured by the length of time the person had been off work (Table 2). Therefore there is no evidence here of selection bias, and the duplicates should provide valid estimates of inter-rater reliability Blackwell Publishing Ltd 287

6 Occupational health audit methodology S. Williams et al. A total of 56% of the back pain data duplicates were entered within 7 days of the initial case being entered, and 85% within 30 days. For depression screening, the figures were very similar at 55% and 84%, respectively. The median kappa score was 0.72 in back pain and 0.80 in depression screening. Only 3/30 categorical questions in back pain and 3/37 in depression screening gave a kappa score below 0.6. None in either audit was below 0.4. Matched responses from the initial and duplicate auditors were compared by the McNemar test. Over both audits, 4/67 questions showed a significant difference; there was no coherent direction to these differences. These are likely to have arisen by chance, as we would expect 3/67 questions to be falsely significant with the standard type I error rate of 5%. Differences on numerical questions were consistent between the two audits: both had 3% of auditors disagreeing on age by more than a year, 5% (back pain) and 6% (depression screening) disagreeing on appointment date by more than a week, and 3% and 5%, respectively, disagreeing on the period of sickness absence by more than 4 weeks. There is no obvious pattern to these disagreements that might explain them in terms of the later data entry of the duplicate finding a later appointment in the notes. Nor are longer waits between initial and duplicate data entry linked with greater numbers of errors. The only apparent pattern is for typographic errors involving month, where differences by 30, 31 or 61 days appear disproportionately. Dissemination of results The audit dissemination conference was attended by 183 OH staff from 60% of participating trusts. During electronic voting, 52% of delegates said that they had changed their clinical practice during data collection and a further 27% said they had done so following receipt of their audit results. Delegates who were actively involved in data collection were more likely to have changed their practice (85%) than those who were not actively involved (63%). The regional workshops were attended by 184 delegates, 120 (65%) of whom had not attended our national conference. Altogether we reached 303 individuals through our conference and workshops. Discussion We have successfully completed the first two national clinical audits of OH care in England, and as far as we are aware, worldwide. We achieved an encouragingly high participation rate for the first round of a new clinical audit. Our participation rate of 72% compares favourably with rates from other first rounds, for example 80% and 75% for national audits of stroke [18] and inflammatory bowel disease, respectively [19]. We faced several challenges when attempting to recruit participants. Firstly, OH practitioners are not familiar with national clinical audit. Secondly, it was particularly important to preserve confidentiality of the records of patients who were staff of the participating trust. In addition, it was challenging to capture at audit the complexity of OH case management which involves communication with the employer as well as clinical interaction with the patient and their health care providers. We were also aware that, in a competitive market place for OH services, prospective audit participants in small OH units might be concerned that scrutiny of their practice would threaten contracts with their commissioning trust. A major challenge was influencing many potential participants who cited very high workload and staff shortages as the main barrier to participation. We believe that we successfully overcame these challenges by using a wide variety of communication modes to engage our audience. These included the launch conference where we demonstrated the audit tool and frequent contact with participants throughout the audit process. The careful design and piloting of our audit tools and help notes produced very good inter-rater reliability. These scores demonstrate the importance of using a rigorous pilot methodology. The final kappa scores, and the clean data produced, suggest that the questions in the audit tools were clear and extraction of data from the case notes was straightforward. Our kappa scores of 0.72 and 0.80 were comparable with those achieved in the first round of the national stroke audit which achieved a median kappa score of 0.70 [20]. For both audits we found a small proportion of sites whose results suggested that the inclusion criteria for cases had been misinterpreted. In the depression screening audit, some sites entered only cases off sick with a psychological diagnosis although physical diagnoses were allowed. This finding could be due to misinterpretation of the instructions for case selection, or due to chance particularly if few cases were entered. It is not possible to assess this quantitatively as one would not expect a constant depression diagnosis prevalence at all sites. In the back pain audit some sites entered only cases that had been off sick, when sickness absence was not a prerequisite for inclusion. Again this may be a misunderstanding of inclusion criteria, particularly given that the audit was running simultaneously with the depression screening audit where sickness absence was a pre-requisite for case inclusion. An alternative explanation is that some OH services may only see those staff where back pain has resulted in sickness absence, with those able to work referred directly to the physiotherapist, whose consultations were not included in this audit. We concluded that these possible misunderstandings of the audit criteria were infrequent, and so were unlikely to bias the data. We will use these findings to inform improvements in the clarity of our instructions on case inclusion criteria in future audit rounds. Once participants had received their audit results we organized both national and regional events to maintain the momentum for quality improvement. While there was some overlap of attendees, the two approaches extended our audience considerably with over 300 delegates from 155 English NHS trusts. These numbers suggest that the audit stimulated a high level of interest in quality improvement. This was supported by the results of the conference voting where 79% of delegates said that they had changed their practice as a result of participating in the audits. The finding that most of these delegates had changed practice even before the audit results were available suggests that audit participation may be a powerful tool for changing behaviour amongst OH clinicians. Although our novel approach of using anonymous, electronic voting has not been validated, we believe it is a useful tool to begin exploring beliefs and behaviours Blackwell Publishing Ltd

7 S. Williams et al. Occupational health audit methodology We have demonstrated that clinical audit can be conducted successfully in the OH specialty. We obtained reliable data, with face validity, that is already stimulating local and national quality improvement activities. Future audits in the area will have baseline data with which to compare and members of the OH profession can build on the knowledge and skills they have acquired during this first round of audit. Our audit methodology would be transferable to other audit topics, and to OH settings in other industries and other countries. Finally, the dissemination and implementation work of the national conference and regional workshops demonstrates that interactive and outreach work is likely to have an important impact on continuing quality improvement. Acknowledgements The audits were commissioned by NHS Plus. OHCEU is a partnership between the Royal College of Physicians and the Faculty of Occupational Medicine. SBH and MH are supported by NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King s College London. IM was supported by NHS Plus and Guy s and St Thomas NHS Foundation Trust. References 1. Intercollegiate Stroke Working Party (2009) National Sentinel Stroke Audit Phase II (Clinical Audit) 2008: Report for England, Wales and Northern Ireland. London: Royal College of Physicians of London. 2. National Audit of Myocardial Infarction Project (MINAP) Steering Group (2007) Management of Acute Coronary Syndromes in England and Wales: A Survey of Facilities in London: Royal College of Physicians of London. 3. Rudd, A., Lowe, D., Irwin, P., Rutledge, Z. & Pearson, M. (2001) National stroke audit: a tool for change? Qualitative Health Care, 10, Jones, J. R., Hodgson, J. T. & Osman, J. (1997) Self-Reported Working Conditions in 1995: Results from a Household Survey. London: Health and Safety Executive. 5. Williams, S., Michie, S. & Pattani, S. (1998) Improving the Health of the NHS Workforce. London: Nuffield Trust. 6. Boorman, S. (2009) Health and Well-Being Review (Interim Report). London: Department of Health. 7. Harvey, S. B., Laird, B., Henderson, M. & Hotopf, M. (2009) The Mental Health of Health Care Professionals. London: Department of Health. 8. Ministerial Task Force for Health Safety and Productivity and The Cabinet Office (2004) Managing Sickness Absence in the Public Sector. London: Health and Safety Executive. 9. Ministerial Task Force for Health Safety and Productivity, T.C.Office (2005) One Year on Report. London: Health and Safety Executive. 10. Healthcare Commission (2005) Acute Hospital Portfolio Review. Ward Staffing. London: Healthcare Commission. 11. Taylor, C., Graham, J., Potts, H. W. W., Candy, J., Richards, M. A. & Ramirez, A. J. (2007) Impact of hospital consultants poor mental health on patient care. British Journal of Psychiatry, 190, National Institute for Health and Clinical Excellence (2004) Depression: Management of Depression in Primary and Secondary Care (CG23). London: National Institute for Health and Clinical Excellence. 13. Waddell, G. & Burton, K. (2000) Occupational Health Guidelines for the Management of Low Back Pain 2000: Evidence Review and Recommendations. London: Faculty of Occupational Medicine. 14. Occupational Health Clinical Effectiveness Unit (2009) Depression Screening and Management of Staff on Long-Term Sickness Absence Occupational Health Practice in the NHS in England: A National Clinical Audit. London: Royal College of Physicians. 15. Occupational Health Clinical Effectiveness Unit (2009) Back Pain Management Occupational Health Practice in the NHS in England: A National Clinical Audit. London: Royal College of Physicians. 16. Grant, R., Batty, G., Aggarwal, R., Lowe, D., Potter, J., Pearson, M., Oborne, A. & Jackson, S. H. D. (2002) National sentinel clinical audit of evidence-based prescribing for older people: methodology and development. Journal of Evaluation in Clinical Practice, 8 (2), National Institute for Health and Clinical Excellence (2007) How to Change Practice: Understand, Identify and Overcome Barriers to Change. London: National Institute for Health and Clinical Excellence. 18. Irwin, P., Rutledge, Z. & Rudd, A. (2001) The feasibility of a national audit of stroke. Journal of Clinical Governance, 6 (1), UK IBD Audit Steering Group (2007) UK IBD Audit 2006: National Results for the Organisation and Process of IBD Care in the UK. London: Royal College of Physicians. 20. Gompertz, P., Irwin, P., Morris, R., Lowe, D., Rutledge, Z., Rudd, A. & Pearson, G. (2001) Reliability and validity of the Intercollegiate Stroke Audit Package. Journal of Evaluation in Clinical Practice, 7, Blackwell Publishing Ltd 289