The perceptions of occupational health in primary care

Occupational Medicine 2005;55:523 527 Published online 1 September 2005 doi:10.1093/occmed/kqi123 The perceptions of occupational health in primary care Joanne Elms 1, Rachel O Hara 1, Simon Pickvance 2, David Fishwick 1, Michelle Hazell 3, Tim Frank 3, Mandy Henson 1, Peter Marlow 1, Gareth Evans 1, Lisa Bradshaw 1, Paul Harvey 4 and Andrew Curran 1 Aim A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs) in Sheffield and Manchester was recruited into a study to evaluate the perceptions of occupational health (OH) in primary care. Methods Qualitative data were collected using focus groups with three groups of primary care sector professionals. Quantitative data were collected nationally from 295 GPs using a postal questionnaire. Results GPs and PNs had minimal OH training, and 60% of GPs reported constraints in addressing OH matters with patients. The lack of referral routes (63 and 67%, respectively) was also seen as a barrier. OH was regarded as a speciality, and primary care professionals preferred to refer patients with OH problems to specialist centres because they perceived barriers to their dealing with the issues. A total of 74% of GPs surveyed thought that speedier access to secondary care would help them to address OH problems. Conclusions This study has identified some of the problems associated with delivering OH through primary care. It also demonstrated a need for greater emphasis on OH education in medical and nurse training, and a need for better advice for GPs, PNs and PMs regarding support services for OH. Key words Occupational health; primary care. Introduction Illness resulting from a patient s work and the impact of this ill-health on a patient s capacity for work are important issues for primary health care. The potential for primary care to improve the health of the workforce has been argued [1] in both industrialized and transitional economies [2]. Work is a major contributor to ill-health among adults [3,4] but it also has a potential role in promoting good health. Additionally, there is value in maintaining the working capacity of employees to increase productivity and to reduce business costs. Recently, the Health and Safety Commission produced an occupational health (OH) strategy Securing Health Together [5]. This included recommendations for measures in the primary 1 Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire SK17 9JN, UK. 2 Sheffield Occupational Health Advisory Service, Queens Building, Queens Street, Sheffield S1 2DX, UK. 3 General Practice Research Unit, North West Lung Research Centre, Manchester M23 9LT, UK. 4 Devonshire Green Medical Centre, 126 Devonshire Street, Sheffield S3 7SF, UK. Correspondence to: Joanne Elms, Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire SK17 9JN, UK. e-mail: Joanne.Elms@hsl.gov.uk care sector to contribute to the goal of reducing workrelated ill-health and sickness absence [6]. It has been suggested that primary care lacks a clear role in the prevention of ill-health and rehabilitation of adults back to work [7]. Published studies emphasize that primary care professionals face difficulties in realizing this role of addressing work-related health issues [8 10]. This report describes results from focus groups carried out with primary care staff, which addressed issues surrounding OH and the provision services. It also reports results from a questionnaire of a random sample of UK general practitioners (GPs) that addressed the same issues. Methods Focus groups were held with GPs, practice nurses (PNs) and practice managers (PMs) in Sheffield and Manchester. This information was supplemented with quantitative data collected from self-administered postal questionnaires. A topic guide was devised based on a review of the literature and following stakeholder discussions. These topics were explored using open questions (Box 1). Primary care professionals were randomly selected from the Sheffield and Manchester areas. Sheffield J. Elms, Health & Safety Laboratory. Ó Crown Copyright 2005. Reproduced with the permission of the Controller of Her Majesty s Stationery Office.

524 OCCUPATIONAL MEDICINE Box 1. Focus group topics 1. What is the provision for patients OH needs within primary care? 2. Should OH be addressed in primary care? 3. What is the involvement of primary care in the provision of OH? 4. What are your sources of OH knowledge and information? 5. What are the barriers to addressing OH in primary care? 6. What would help in overcoming the barriers? 7. How is OH information gathered? 8. The impact of MED 3 sickness certification. currently has a city-wide OH advisory service [the Sheffield OH Advisory Service (SOHAS)], which provides advice and information for individuals with work-related health problems; it operates from GPs surgeries. To limit the possible bias from an enhanced awareness of OH in this group, Manchester was also chosen as a second site for the study. Focus group participants were drawn from diverse geographic and demographic areas. The participants were contacted by telephone (by a member of the study team) and invited to attend the focus groups. Two separate focus groups were conducted for each stakeholder group. To encourage uninhibited discussion, separate focus groups were held for GPs, PNs and PMs. Two members of the study team attended each session: a facilitator to introduce the questions and to probe the issues raised, and a note taker who also audiotaped each discussion. Two members of the research team independently reviewed the written accounts and audiotapes of each discussion. Themes for each group of stakeholders were then collated to provide an agreed account of the issues identified across the groups and to identify differences between the groups and regions. Key issues identified from the focus groups were used to develop the GP postal questionnaire. This was sent to 1000 UK GPs, selected randomly from all principal GPs on the medical register. A follow-up questionnaire was sent to non-responders. Questionnaire responses were analysed using SPSS software (SPSS version 10, SPSS Incorporated, Chicago, IL, USA). Descriptive statistical analysis was performed on the data. Results A total of 22 GPs, 25 PNs and 24 PMs participated in the focus groups. The response rate for the postal questionnaire was 30% (295 questionnaires), which is consistent with other established postal questionnaire studies [11]. The questionnaire respondents had worked in general practice for a mean of 16 years (range 2 40 years); 57% were male. The main OH disorders encountered by the primary care staff within their patient groups were musculoskeletal and mental health problems. Focus group participants considered it difficult to quantify the extent to which they encountered OH problems as this information is not routinely recorded on patient record systems. The questionnaire survey revealed that 75% of GPs asked the patients about their occupation and 81% recorded the type of occupation in the medical records. Table 1 illustrates changes in work-related health problems over the preceding 18 months. The main increase was related to mental health problems. GPs enquired about patients occupation when they considered it relevant to the presenting complaint. PNs routinely asked about patients occupation (Box 2). GPs and PNs were offered minimal OH education during their training. They felt ill-equipped to deal with some of the OH-related demands they encountered. Only 4% of the questionnaire respondents had any OH qualifications. A total of 73% of GPs learnt about OH while practising, and 50% said that they received this OH information from colleagues. The three stakeholder groups thought that primary care had a limited role in addressing OH problems. They felt that employers needed to take more responsibility and there was a need for increased state provision for those patients without OH services at their place of employment. Greater clarity regarding the respective roles and responsibilities of employer OH services versus primary care services was also required. Barriers to addressing OH needs Limited OH knowledge made it difficult for GPs and PNs to assess OH problems and provide advice in this area (Box 2). A total of 62% thought that more training was required and 58% thought that information sheets would help them to address these OH problems. OH was regarded as a speciality and the focus group participants wanted experts to whom they could refer patients, rather than having to become experts themselves. Time constraints were a limiting factor for GPs and PNs when they tried to explore OH problems with patients or when they tried to refer them to secondary care centres. The questionnaire findings highlighted long waiting times for specialist services and a lack of referral routes, as highlighted by 67 and 57% of GPs, respectively (Table 2). Accordingly, speedier access to secondary care (74%) and improved referral routes (66%) were identified as factors that would help GPs to address the patients OH needs. PMs suggested that increased funding for practices to refer patients to support services such as

J. ELMS ET AL.: PERCEPTIONS OF OH IN PRIMARY CARE 525 Table 1. Percentage (number) of GP respondents by frequency with which GP work-related problems were encountered Question Increase, No change, Decrease, encounter work-related mental health problems in patient consultations? encounter work-related musculoskeletal problems in patient consultations? encounter work-related skin health problems in patient consultations? encounter work-related respiratory problems in patient consultations? encounter work-related hearing problems in patient consultations? encounter work-related visual/eye problems in patient consultations? 58 (169) 42 (123) 0.0 (0) 27 (79) 71 (207) 2 (5) 8 (22) 90 (259) 2 (7) 8 (22) 89 (257) 3 (10) 2 (6) 94 (271) 4 (12) 3 (9) 94 (270) 3 (9) Box 2. Involvement in addressing OH issues PNs group (Sheffield) PN 1: PNs treat patients holistically. We re not just seeing them for one narrow thing. Often they ve got multiple things, especially with chronic disease management; so we re looking at all aspects of their life. GP group (Sheffield) GP 5: It s often a bit difficult if you don t know what people do at work to advise whether it s appropriate for them to go back. There was a particular person who had a pin in his hip and back and he could drive certain kinds of vehicles but he couldn t climb up and down to secure loads. He had a lot of input from OH and the OT [occupational therapy] department and others. They couldn t agree so they asked me and I hadn t really much evidence to base a decision on except what the [patient] told me. PMs group (Manchester) PM 5: We re not in the position that we have funds to buy in services; that was the position when we were fund holding and we certainly did buy in an osteopath and physio as the hospital waiting lists were so long but that s not available to us anymore. counselling and physiotherapy would help to address some OH needs (Box 2). All the focus groups raised the issue of patient confidentiality and perceived a conflict of interest between primary care practice and the employers OH provision. This concern was reinforced when they encountered patients who were afraid to involve their employers OH service. However, the questionnaire showed that conflicts of interest between the patients and their employer (21%) or the issue of patient confidentiality (17%) were not barriers for most of the GPs surveyed (Table 2). UK GPs are required to sign medical certificates for periods of sickness of 8 days or more and arguments were presented by the GPs regarding their involvement in this process. The reason for their opposition appeared to be the perception that they were not always best qualified to make these judgements, and the majority (70%) relied on their patients judgement regarding their fitness to work. However, the fact that patients had to attend surgery made the GP aware of their illness. Additionally, it encouraged them to discuss the patient s work and provided an opportunity for contact with the employer. The majority of questionnaire respondents (84%) agreed that employers not accepting self-certification had increased their workload, and 47% thought that GPs should not provide (Med3) sickness certification (Table 3). Knowledge of SOHAS among the Sheffield nurses was limited, with only 5 out of 14 being aware of the service. Once aware of SOHAS, Sheffield nurses requested further information as they felt it would be a useful resource for them. Nurses from practices that either previously had or currently have a SOHAS advisor for their patients thought it was a useful service and had referred their patients. However, one of the nurses felt that this service was not fully utilized.

526 OCCUPATIONAL MEDICINE Table 2. Percentage (number) of GP respondents reporting barriers to addressing OH problems Question Yes, % (n) No, % (n) Do waiting times for specialist services make it difficult for you to address patients occupational Does the consultation time make it difficult for you to address patients occupational Does lack of training make it difficult for you to address patients occupational Does lack of referral routes make it difficult for you to address patients occupational Does conflict of interest make it difficult for you to address patients occupational Does confidentiality make it difficult for you to address patients occupational health problems? 67 (193) 33 (96) 63 (181) 37 (108) 60 (172) 40 (117) 57 (166) 43 (123) 21 (60) 79 (229) 17 (49) 83 (240) Table 3. Percentage (number) of GP respondents by level of agreement with statements regarding OH in primary care Statement GP should be concerned with addressing occupational causes of ill-health I do not have time to explore OH issues in patient consultations I feel competent to explore possible OH problems in patients Further training would improve my ability to address OH issues for patients MED 3 sickness certification is a useful tool for communicating with patients employers MED 3 sickness certification should continue to be provided by GPs OH physicians are more concerned with reducing absenteeism than what is best for individuals Doctor patient confidentiality prevents GP s communication with the employer of patients I do not have sufficient knowledge to assess fitness to work I tend to rely on the patient s judgement regarding fitness to work Long waiting lists for secondary referrals prevent patients from returning to work earlier My workload has been increased by employers not accepting self-certification GPs can only advise patients to speak to their employers about work-related health problems I am not aware of services to refer patients with OH problems Strongly agree, % (n) Agree, Unsure, Disagree, 18 (54) 65 (189) 10 (29) 6 (18) 1 (3) 6 (18) 35 (102) 12 (35) 44 (129) 3 (7) 4 (12) 44 (129) 34 (100) 16 (47) 2 (4) 12 (36) 71 (209) 13 (38) 3 (9) 0 (1) 0 (1) 17 (49) 15 (45) 51 (150) 16 (47) 1 (3) 29 (85) 23 (66) 35 (102) 12 (36) 2 (5) 23 (67) 34 (100) 39 (114) 3 (8) 13 (39) 46 (133) 13 (38) 27 (77) 1 (3) 8 (24) 36 (107) 22 (64) 31 (89) 3 (8) 10 (28) 60 (178) 10 (28) 18 (54) 2 (5) 36 (107) 52 (154) 9 (25) 3 (8) 0 (0) 37 (107) 47 (138) 4 (12) 12 (35) 0 (1) 7 (21) 52 (151) 16 (48) 23 (66) 2 (5) 7 (21) 48 (141) 17 (49) 26 (75) 2 (5) Strongly disagree, % (n) Manchester PNs indicated that they would find it helpful to have an OH specialist based locally or within the practice. Discussion The focus groups identified a number of specific issues that were further investigated using the postal questionnaire. Of specific concern was the lack of professional training and knowledge in OH and access to appropriate routes for referral of patients. The groups identified that primary care had a role to play in relation to a patient s OH problems, but suggested that employers should take more responsibility. There was also a requirement for improved state provision for these patients. It was generally reported that GPs and

J. ELMS ET AL.: PERCEPTIONS OF OH IN PRIMARY CARE 527 PNs take a focused approach to exploring patients occupation, although their lack of OH knowledge left them poorly equipped to deal with some of the issues that arose. This issue has been highlighted in the literature [3,12,13] and has promoted discussions over how to address the poor coverage of OH within the medical curriculum and postgraduate training. However, the majority of GPs and PNs participating in the focus groups felt that substantial training was not the solution. OH is regarded as a specialism in itself, and the focus group participants wanted experts to whom they could refer patients, rather than becoming experts themselves. This may have been a contributory factor to the low uptake of an OH distance learning package for GPs and other primary health care staff [14]. All three groups said that they would be more willing to record OH information if there were better procedures for doing this. It was considered that the roles of the employer versus the primary care staff were not well defined. It was frequently reported that employers take insufficient responsibility for the health of their employees and that employers often transferred their responsibility onto an overstretched primary care service. Poor routes of communication with the employer often contributed to this problem. Referral of patients to specialist services (particularly for mental health and musculoskeletal problems) usually encountered long delays. The groups were asked why OH was being given a low priority in their work. It was regarded as a specialism by most GPs so they were less likely to allocate time and resources. The pressure to deliver many other health targets prevented them from investigating OH needs. Ethical barriers also existed, for example communication with the employer about potential conflicts of interest between the employer and the employee. These issues were particularly relevant to sickness certification and fitness to work. Economic pressures also limited the uptake of specialist services, and these prevented GPs from investigating the full history of occupational illness. Specialist services were usually expensive and ring fenced ; funding was needed for these services at national and regional levels. Several areas for improvement were highlighted, such as systems to record and evaluate OH without adding a burden to hard-pressed resources, improved access to information and advisory services for OH, and simple screening questionnaires for primary care teams to identify patients with OH problems. Support should be given to national initiatives to improve resources for OH within primary care and priority should be given to mental health, stress and musculoskeletal problems, with counselling and physiotherapy services seen as key resources. Training and professional development in OH for primary care staff should also be offered, such as use of the protected learning time initiative scheme. This study has demonstrated a need for greater emphasis on OH in medical and nurse training and better advice for GPs, PMs and PNs, regarding support services for OH. Conflicts of interest None declared. References 1. Vaughan Jones JAL. The GP and industrial health (The 6th James Mackenzie Lecture). J Coll Gen Pract 1960;3:9 32. 2. Kocks DJ, Ross MH. The financial components and contribution of OH services to the provision of primary health are services in a developing country such as South Africa. Occup Med (Lond) 1995;45:156 158. 3. D Auria D. Occupational medicine and GPs. Practitioner 1989;233:1511. 4. Harber P. Primary care role in preventing occupational and environmental respiratory disease. Prim Care 1994;21: 291 311. 5. Securing Health Together; A Long-Term OH Strategy for England, Scotland and Wales. London: HSE Books. 6. 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General practitioners miss disability and anxiety as well as depression in their patients with osteoarthritis. Br J Gen Pract 2000;50:645 648. 14. Centre for Health Policy and Practice. OH in General Practice. Distance Learning Package. Stafford, UK: Staffordshire University, 2000.