Audit of pre-employment assessments by occupational health departments in the National Health Service

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1 IIITTERWORTH I; E I N E M A N N (94)8-5 Occup. Ued. Vol. 45. No 2, pp Copyright 1995 ElMvi«r Scl«nt» Ltd lof SOM Printed In Qrut Britain. All rights resarvsd /95 $ Audit of pre-employment assessments by occupational health departments in the National Health Service S. Whitaker and T.-C. Aw Institute of Occupational Health, University of Birmingham, Edgbaston, Birmingham, UK Pre-employment health assessment of applicants to the National Health Service (NHS) is one of the functions of occupational health departments in the NHS. This paper describes the results of a process and outcome audit of this activity, concentrating on the current practice of occupational health departments. The audit was carried out by 4 NHS occupational health units who provided information on a standard questionnaire on all pre-employment assessments undertaken over a three-month period. This produced 9139 questionnaire returns. The analysis showed that the most common method of assessment was the use of a self-administered questionnaire alone (49.4%). A self-administered questionnaire followed by a nurse interview as standard practice was the next most common method (34.1%), but referral to a physician was uncommon. The outcome of the assessments for 98% of all applicants was 'fit for work'. A total of 12 individuals (1.3%) were assessed as 'fit to work, but with some restriction' and 65 individuals (.7%) were considered 'unfit'. The most common reasons for rejection were abnormal body mass index (4%), skin conditions (21.5%) and psychiatric conditions (1.8%). The most common reasons for restriction were musculoskeletal conditions (27.5%), skin conditions (15%) and abnormal body mass index and psychiatric conditions (both 1.8%). The audit identified wide variation between occupational health departments in the NHS in the practice of restriction and rejection. A decision on the value of pre-employment assessment in the NHS must take into consideration the ability of the process to achieve its aim, the time and manpower involved in the process, and the probability of low restriction and rejection rates. These factors should be balanced against the potential risk to the employee, colleagues and the public if allowed into employment. A common standardized approach to pre-employment assessment should be considered by occupational health departments in the NHS. Occup. Mod. Vol. 45, No. 2, pp. 75-8, 1995 In 1991, the Department of Health sent out a circular outlining arrangements required for medical audit in the health service 1. Since then, there has been some progress in the areas of medical and clinical audit. The latter is an activity that is not confined to physicians but also involves other healthcare professionals such as clinical nurses. Occupational health practice in the health service is an area of clinical activity that is performed by both doctors and nurses. Within such practice, pre-employment assessment of new employees is a procedure carried out by all occupational health departments. The process and outcome of such assessments have not been previously audited on a national scale. This study details thefindingsof an audit Correspondence and reprint requests to: Mr Stuart Whitaker, Institute of Occupational Health, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. on pre-employment assessments by occupational health departments in the health service. The aims of the audit were: (i) to determine the current methods used for preemployment assessment, and (ii) to describe and compare the outcome of preemployment assessment between units, in terms of fitness to work, i.e.fitfor employment,fitwith some restriction, or unfit. METHODS A questionnaire was designed which was to be completed for each pre-employment assessment undertaken by participating occupational health units over a three-month period (1 January 1993 to 31 March 1993). Downloaded from by guest on 16 September 218

2 76 Occup. Med. Vol. 45, No. 2, 1995 The questionnaire required information on the job category, the method of pre-employment assessment, and the result of that assessment. Additional information was gathered on applicants who were rejected or who had restrictions placed on their employment. A pilot study was undertaken in seven NHS occupational health units in the West Midlands. This was followed by the national study which was carried out throughout England and Wales. All occupational health units in the NHS in England and Wales which could be identified from the databases held by the Association of NHS Occupational Physicians (ANHOPS), the Institute of Occupational Health, the Department of Health and the Royal College of Nursing were included in the study. A sample of 65 units from this list of 217 units was selected for participation in the study using random number tables. These units were invited to participate in the study by a letter to the occupational health manager. Forty units agreed to participate (62% participation rate); these forty units represent 18% of the total number of identified units. Questionnaires were returned to the Institute of Occupational Health at Birmingham University and data were entered onto a Apple Macintosh computer database. The statistical package SPSS was used to analyse the data and the x 2 test of statistical significance was used to test the data. RESULTS Table 1 summarizes the different methods used for the pre-employment assessments and the outcome of those assessments. The majority of pre-employment assessments (4517) were undertaken by self-administered questionnaire alone. These questionnaires were evaluated either by occupational health nurses or physicians. In Table 1. Pre-employment assessment: methods and outcome Method of assessment Self-administered questionnaire Self-administered questionnaire and a nurse interview following identification of a problem Self-administered questionnaire and a nurse interview as standard practice total, 3116 assessments were performed by the use of self-administered questionnaires and a nurse interview as standard practice. Other methods of assessment were less common. The highest rejection rate (6.2%) occurred when a self-administered questionnaire was followed by a nurse interview which led to referral to a doctor for assessment because a problem was identified. The rejection rate by use of a self-administered questionnaire alone, with applicants being called for nurse interview only when problems were identified, was not found to be statistically significantly different from the rejection rate when the self-administered questionnaire was followed by a nurse interview as standard practice. Figure 1 and Table 2 show the outcome of 9139 pre-employment assessments performed by the participating units over the three-month study period. The lowest percentage of applicants declared fit by any unit was 86.3% (unit Nl: restriction rate 13.7%). The overall restriction rate varied between % (no restrictions) and 13.7%. The rejection rate varied from % to a maximum of 5.3%. Table 3 shows the rejection rates by occupational group. These have been ranked from highest to lowest rejection rate. The largest number of rejections occurred in student nurses (17) and nursing assistants (14). Although technicians were shown to have the highest rejection rate, this is based on small numbers of technicians in the study. Table 4 describes the conditions which resulted in rejection for the 65 applicants. An abnormal body mass index (BMI > 3 kg/m 2 ) was the commonest reason for rejection. The most common job categories for which body mass index resulted in rejection at pre-employment assessment were student nurses (7) and nursing assistants (6). Where multiple conditions were the cause of rejection the occupational health assessed Restricted n %.4% 2.6%.8% n Rejected %.2% 1.%.5% Downloaded from by guest on 16 September 218 Self-administered questionnaire and a nurse interview, with referral for a doctor's examination following identification of a problem %?4 6.2% Self-administered questionnaire, and a nurse interview and doctor's examination as standard practice % 2 1.% Nurse-administered questionnaire 41 Nurse-administered questionnaire and referral for a doctor's examination following identification of a problem 3 Nurse-admlnistered questionnaire and doctor's examination as standard practice 2 Other % 7 3.8%

3 S. Whitaker and T.-C. Aw: Audit of pre-employment assessments 77 Rate (Percentage) A C E G I K M O Q S U W Y A1 C1 E1 G1 11 K1 M B D F H J L N P R T V X Z B1 D1 F1 H1 J1 L1 N1 * * UnttNl had a restriction rate of 13.7% Unit Code Assessed Rejected Restricted! Figure 1. Individual restriction and rejection rates of the 4 participating units. The number of assessments undertaken by participating units during the study period varied from 46 to 66, with the median figure being 198. There was considerable variation in the outcome of pre-employment assessments between units. During the study period, in addition to passing applicants 'fit' for employment, four of the units also used 'rejection' without any restrictions, 12 of the units used only 'restriction' without any rejections, and 14 units used both 'restriction' and 'rejection'. Ten units did not restrict or reject any applicants. Table 2. Outcome of pre-employment assessments Assessment decision of subjects Fit Restricted Rejected Total Table 3. Rejection rates by occupational group Occupational group rejected Technician 3 Student nurse 17 Catering staff 4 Nursing assistant 14 Physiotherapist 1 Clerical staff 3 Qualified nurse 7 Domestic staff 2 Administrative staff 1 Doctor 1 Other 12 Total 65 assessed Percentage 98.% 1.3%.7% Rejection rate 3.4% 1.7% 1.7% 1.5%.8%.4%.3%.3%.2%.9%.7%.7% departments were asked to identify only the main condition for rejection. Table 5 shows the restriction rates by occupational group. These have been ranked from highest to lowest Table4. Clinical conditions resulting in rejection at pre-employment Condition Abnormal body mass index Skin conditions Psychiatric conditions Musculo-skeletal conditions Raised blood pressure Various others rejected Tabl* 5. Restriction rates by occupational group restricted assessed Percentage 4.% 21.5% 1.8% 6.2% 3.1% 18.5% Restriction rate Pharmacist % Theatre technician % Porter % Works stafi % Laboratory technician % Domestic start % Catering staff % Physiotherapist % Nursing assistant % Student nurse % Technician % Qualified nurse % Clerical staff % Administrative stafi % Doctor % Other % Total % Downloaded from by guest on 16 September 218

78 Occup. Med. Vol. 45, No. 2. 1995 Table 6.

4 78 Occup. Med. Vol. 45, No Table 6. Restriction rates by clinical condition Condition Musculo-skeletal conditions Skin conditions Abnormal body mass index Psychiatric disorder Hypertension Asthma Epilepsy Other conditions Total restricted Percentage 27.5% 15.% 1.8% 1.8% 7.5% 3.3% 2.5% 22.5% restriction rate. The largest number of restrictions were found in qualified nurses (21), domestic staff (15), nursing assistants (14) and student nurses (13). Table 6 shows the restriction rate by clinical condition. Musculo-skeletal conditions, skin conditions, abnormal body mass index and psychiatric disorders were the most common conditions which resulted in restriction. Small numbers of various conditions such as post-hysterectomy, pregnancy or varicose veins are included under 'other conditions'. The most common types of restriction were that the applicant should be reviewed by occupational healdi staff within three months (35%; n = 42), or that they should be offered a temporary contract, with or without review (2%; n = 24). DISCUSSION The audit process described in this paper has started by examining the current practice of pre-employment assessment in the NHS. Future work is designed to establish standards of practice, which in turn can be further evaluated in order to complete the audit cycle. In this way, it is envisaged that a process of continual improvement will be introduced to pre-employment assessment in the NHS. From the audit, we can estimate that some 2 pre-employment assessments are carried out by NHS occupational health units per year. The assessment process is therefore a substantial activity of NHS occupational health units. However Figure 1 demonstrates the wide variation between occupational health units in the use of restriction and rejection at pre-employment assessment. This study covers a total of 9139 assessments carried out over a three-month period by 4 of die 217 identified units in England and Wales. The audit was focused on the outcome of pre-employment assessment in relation to those who were restricted or rejected, while those who were allowed into employment were not considered in detail, and this important area remains open for investigation by means of a well-constructed prospective longitudinal study. It has been suggested that the primary purpose of pre-employment assessment is to ensure that an individual is fit to perform die task involved effectively and without risk to his own or others' health and safety 2. This includes ensuring that a reasonable match between the individual and the job exists, and that diere are no major adverse factors which may affect die person, the job, other workers or third parties such as customers, clients, visitors and patients. However, die assessment of large numbers of job applicants may be a timeconsuming exercise involving occupational health personnel. An audit of this common activity provides some insight into die results of this activity. A total of 98% of all of the pre-employment assessments undertaken by participating units during die three-mondi study period resulted in die applicants being considered fit for employment; only 2% were restricted or rejected. This rejection/restriction rate (1 in 5) is useful when considering the methods of pre-employment assessment. Arguments for discontinuing or reducing the commitment to this activity have to be balanced against the nature and severity of the conditions detected and the consequences of not detecting them early. For example, musculo-skeletal and skin disorders may deteriorate given the wrong work activities or workplace exposures. The detection of diese conditions is vital to die prevention of further ill-healdi and injury. Therefore, even when diese conditions occur only occasionally, detection at a pre-employment stage will benefit die individual and die organization. The purpose of pre-employment assessment is sometimes not clearly defined by die providers of occupational health care. Occupational health departments widiin the healdi service and in industry have used the occasion for purposes such as healdi promotion, gathering baseline information on heakh, or for introducing the occupational health staff and service to die employees. It is necessary to be clear about die purpose of questions asked at pre-employment assessment in order to evaluate their usefulness. Arranging a medical examination for all job applicants has been criticized as wasteful of resources and of little benefit to the employer, employee or physician 3 " 4. This study shows that the rate of rejection by diis procedure is not statistically significantly higher than by the staged process of assessment which allows for referral to a physician where problems are identified at an earlier stage of assessment. Other studies 5 have indicated diat medical examinations at pre-employment assessment did result in more conditions being detected, although die conditions which were detected did not necessarily result in a higher rate of rejection. The use of a self-administered questionnaire followed by nurse interview only as a result of problems being identified is a system of pre-employment assessment which is widely used in die NHS. The use of a self-administered questionnaire and nurse interview for all applicants as standard practice is also widely used. Both methods of assessment allow for referral to an occupational physician where necessary. In diis study, Downloaded from by guest on 16 September 218

S. Whitaker and T.-C. Aw. Audit of pre-employment assessments 79 there was no significant difference in the restriction or rejection rates for either method of assessment.

5 S. Whitaker and T.-C. Aw. Audit of pre-employment assessments 79 there was no significant difference in the restriction or rejection rates for either method of assessment. As the use of a nurse interview as standard practice for all applicants does have significant resource implications, any additional benefits gained by continuing this practice should be clearly identified and evaluated. This study demonstrates that a small number of applicants were rejected on the basis of information supplied on the self-administered questionnaire alone, and that a larger number of applicants were rejected at the nurse interview stage. The rejection rate for student nurses, nursing assistants and catering workers far exceeds that of qualified nurses, qualified physiotherapists or doctors. Qualified staff may have a lower rejection rate than staff in training because those who had health problems related to the work should have been selected out in the course of training. There may also be an element of self-selection for posts or an effect of previous occupational health screening. Alternatively, it may be due to an improved ability to conceal relevant factors at pre-employment assessment. The nature of a training post may mean a greater variety of exposure when compared to a relatively stable, permanent post. Occupational halth professionals may be more inclined to advise on suitability for commencement of training and alternative career paths for training grades, whereas they may be more reluctant to advise on major job changes for those who are already qualified and committed to a career. The most common reason for rejection (4% of all of those rejected) was an abnormal body mass index and this was typically those found to have a body mass index (BMI) in excess of 3kg/m 2. The body mass index is calculated by dividing weight (kg) by height (m 2 ) and the scale is through to be appropriate for judging obesity in adult men and usually gives satisfactory values for adult women; however, the scale does need to be modified for use with adolescents 6. The most common job categories for which abnormal BMI resulted in rejection at pre-employment assessment were student nurses (n = 7) and nursing assistants (n = 6). No doctors, technicians or administrators were rejected because of an abnormal BMI. Either these occupational groups were within the normal limits of the BMI scale or an abnormal BMI was not considered to be relevant to the job activities which they have to perform. If the reason for rejection is because of obesity increasing the risk of morbidity 7, which may lead to absence from work, both the degree of obesity and the circumstances of work should be considered. The use of obesity as a predictor of future ill-health or attendance at work should be treated with caution, particularly in women from different ethnic groups, as it has been suggested that the causes of obesity and its significance to health are not the same in these groups as in white women 8. An additional point is that, if increased morbidity and mortality is of concern at pre-employment assessment, smoking history is of greater significance 6. If a significant loss of functional ability is thought to arise because of an abnormal BMI, then both the degree of obesity and loss of function should be assessed. Some of those rejected because of obesity were rejected on the basis of a questionnaire alone. Some authors 3 have advocated rejection from employment on health grounds only after individual assessment by a physician. One of the benefits of participation in this audit exercise was that the units with procedures not in keeping with the majority of their colleagues may decide whether or not a change in practice is warranted. However, in some instances, the practice of the minority may indeed be the most appropriate. CONCLUSION Occupational health professionals have a role to play in reducing the risk to employees' health and safety, and pre-employment assessment is one aspect of that role. However, the assessment process has limitations in terms of its ability to detect clinical conditions and to predict the health status of employees once in employment. This study has shown that the rejection rate achieved by medical examination as standard practice does not achieve a significantly higher rate of rejection than by the use of a multi-stage screening exercise that refers the cases with identified problems to an occupational health nurse and then a physician. Given the large numbers of applicants who are found to be fit for employment on assessment, it is essential that scarce occupational health resources are not used on labour-intensive screening programmes, the results of which could be achieved by simpler methods of assessment. Pre-employment assessments targeted at specific occupational groups, focusing on the common medical conditions that lead to rejection or restriction and using a common standardized approach, should be considered by occupational health departments in the health service. ACKNOWLEDGEMENTS The authors are grateful to the Department of Health for financial support, the Association of NHS Occupational Physicians (ANHOPS) for participation and guidance on this project, Mr Ian Calvert for statistical support, and all the occupational health units who took part in the audit exercise for their commitment to the audit process. REFERENCES 1. Department of Health. Working for Patients: Medical Audit - Working Paper No. 6. London: HMSO, Edwards FC, McCallum RI, Taylor PJ. Fitness to Downloaded from by guest on 16 September 218

6 8 Occup. Med. Vol. 45, No. 2, 1995 work - the medical aspects. Oxford: Royal College of Physicians/Oxford Medical Publications, 1991: 6. Lunn JA, Waldron HA. Concerning the carers. Oxford: 6. Royal College of Physicians. Obesity. J R Coll Phys Land 1983; 17(1): 6, 1. Butterworth Heinemann Ltd, 1991: 23, Lew EA, Garfinkel L. Variations in mortality by weight 4. Harte JD. Is the pre-employment medical examination of value? Proc R Soc Med 1973; 67: among 75, men and women. J Chron Dis 1979; 32: Schussler T, Kaminer AJ, Power VL, Pomper IH. The preplacement examination. J Occup Med 1975; 17(4): 8. Walker ARP, Segal I. The puzzle of obesity in the African black female. Lancet 198; ii: 263. Downloaded from by guest on 16 September 218

17. Updates on Progress from Last Year s JSNA

17. Updates on Progress from Last Year s JSNA 3. The Health of People in Bromley NHS Health Checks The previous JSNA reported that 35 (0.5%) patients were identified through NHS Health Checks with non-diabetic