The perceptions of occupational health in primary care

Abstract

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 care sector to contribute to the goal of reducing work-related 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 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 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.

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 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