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.     

Ill-health retirement of schoolteachers in the Republic of Ireland

BACKGROUND: To investigate the epidemiological profile and medical causes of ill-health retirement (IHR) of teachers in the Republic of Ireland. METHODS: Medical file review of teacher IHR in Irish primary and secondary schools, between 2002 and 2005 inclusive. RESULTS: In all, 466 employees were granted IHR between 2002 and 2005.The rate of IHR was 2.7/1000 teachers per annum, with an average age at IHR of 52 years. The most common reasons for IHR were mental disorders (46%), cancer (19%), circulatory (14%) and musculoskeletal disorders (10%). CONCLUSIONS: The rate of IHR among Irish teachers is similar to that of other occupational groups, with psychiatric conditions, cancer and circulatory diseases as the principal causes.     

Ill-health retirement among healthcare workers in the Southern Health Board of the Republic of Ireland

AIM: To determine the incidence rates, trends and medical causes of ill-health retirement (IHR) among different occupational classes in the Southern Health Board (SHB). METHODS: The 14 702 permanent employees of the SHB were divided into six occupational classes based on socio-economic status and occupational demands. The occupational classes were compared for incidence rates of IHR, age at IHR, years of service and medical causes of IHR. The total group of employees was used as the standard for statistical comparison. Incidence rates were compared using standardized IHR ratios (SIHRRs). Medical causes were compared using proportional ill-health retirement ratios (PIHRRs). RESULTS: Three hundred and three employees were granted IHR from 1994 to 2000.The overall incidence rate of IHR was 2.9 per 1000 employees per annum. The highest SIHRRs occurred in male maintenance staff at 345 (CI: 221-513) and female support staff at 158 (CI: 123-201). With regard to age and years of service, IHR peaked at a time that coincided with enhancement to pension entitlements. The common causes of IHR were musculoskeletal disorder (38%), mental illness(17%), circulatory disorder (12%) and neoplasia (8%). PIHRRs did not vary significantly between the classes. CONCLUSION: IHR was more common among manual healthcare workers. The structure of the pension scheme appeared to influence the timing of IHR. Occupational class did not appear to influence the medical causes of IHR.     

Ill health retirement in Scottish teachers: process, outcomes and re-employment

Objectives: To assess the process, causes and outcomes of ill health retirement (IHR) in teachers in Scotland. Perceptions and experience of occupational health services (OHS), access to rehabilitation and redeployment, current health, post retirement experience and predictors of re-employment were identified. Methods: 537 teachers who retired due to ill health between April 1998 and March 2000 were mailed our IHR questionnaire by the Scottish Public Pensions Agency. Results: The most common cause of IHR was mental disorders (37%), followed by diseases of the musculoskeletal system (18%). 11% of teachers attended an OHS prior to IHR. 9% of teachers were offered part-time work and 5% were offered alternative work. 63% of retired teachers stated their health had improved and 48% said they would like to work again. 36% of the surveyed teachers have found re-employment since their retirement. On unadjusted analyses, re-employment of teachers after IHR was significantly associated with sex, having dependants, job group, cause of IHR, health having improved and wanting to work again. Multiple logistic regression analyses showed three variables as independent predictors of re-employment: having dependants, job group and cause of IHR. Conclusion: This is the first comprehensive study investigating teachers’ experiences of IHR in Scotland. The findings highlight substantial lack of support for teachers in a number of areas which need to be addressed by managers and employers. Our study confirms the need for rehabilitation and teacher support services in order to try and retain experienced teachers in the profession.     

Ill-health retirement: national rates and updated guidance for occupational physicians

BACKGROUND: Advising on ill-health retirement is an important role of most practising occupational physicians. In recent years, the eligibility criteria and process for gaining early retirement benefits have changed in many pension schemes in the UK. AIM: To investigate the variation in rates of retirement due to ill-health in National Health Service (NHS) Trusts and Local Authorities and to update previously published guidance on ill-health retirement with specific reference to pension schemes with eligibility criteria that include permanence of incapacity due to ill-health. METHODS: Rates of retirement were calculated for 222 NHS Trusts and 132 Local Authorities with more than 1500 employees. Literature searches and consensus statements by the authors. RESULTS: Rates of retirement were widely distributed in the NHS Trusts and Local Authorities. The median rates of retirement were 2.11 (IQR 1.37-2.91)/1000 active members and 4.10 (IQR 3.01-6.10)/1000 employees, respectively (P<0.001). Difficulties in the doctor-patient relationship and in ascertaining the true functional ability of some patients were identified. CONCLUSION: There continues to be marked variation in rates of early retirement due to ill-health within and between organizations that warrants further investigation. The general and specific guidance that appears as an appendix in Supplementary data to this paper should help occupational physicians to make equitable recommendations when assessing applications for early retirement benefits and fitness to work.     

The management of occupational health by NHS Trusts in the north of England

This paper reports the findings of an audit of the management of occupational health arrangements in 36 NHS Trusts in the Northern and Yorkshire region of England. A questionnaire was designed based on a national NHS occupational health standard to obtain data on eight categories of occupational health activity: health and safety; pre-employment assessments; Infection Control; health surveillance; sickness absence; ill-health retirement; health promotion and record storage. The management arrangements for occupational health were varied. Assessments of workplace hazards, prevention of HIV-positive workers from performing exposure-prone invasive procedures and the assessment of pregnant workers were identified as issues for further consideration. Provision of competent and effective occupational health services will assist in the management of sickness absence and in the protection and promotion of health of staff. It will also contribute to the health and safety of patients.     

Occupational health services in the UK--challenges and opportunities

BACKGROUND: A small minority of the UK workforce currently has access to an occupational physician. Reduction in the size of enterprises, the emergence of atypical work patterns and problems recruiting and training occupational health specialists risk making this minority even smaller. AIM: This paper considers the challenges currently facing occupational medicine and how we can improve access to occupational health services (OHS). It aims to highlight some of the diverse internal and external factors that restrict the UK's ability to provide all workers access to OHS. METHOD: A literature review was carried out and combined with awareness of current trends in business and new legislation together with provision of occupational medicine in other countries. RESULTS: Potentially controversial solutions that might help to make OHS more widely accessible were identified and are discussed. It is hoped that these will provoke further debate. CONCLUSION: Individually and organizationally, we must examine and improve capabilities if we are to improve worker access to OHS and deliver targets to reduce occupational ill-health. It is suggested that this requires a strategic shift to apply resources differently. There is need to explore delegation of tasks traditionally performed by doctors to nurses and other staff together with the outsourcing of non-core work. The increased use of telemedicine and the enhanced use of information technology for training, risk assessments, wellness programmes and questionnaire-based health assessments are other developments that should be explored.     

The reported incidence of work-related ill-health in Scotland (2002-2003)

BACKGROUND: Although incidence data for work-related ill-health in the UK are available, more detailed information for smaller geographical areas has hitherto been unpublished. AIMS: To estimate the incidence of work-related ill-health reported by clinical specialists in Scotland, 2002-2003. METHODS: THOR (The Health and Occupation Reporting network) is a UK wide reporting scheme for work-related ill-health. In 2002-2003, 241 out of 2162 physicians in THOR were based in Scotland. We have summarized the reported cases and calculated incidence rates for categories of ill-health by age, gender and industry. The UK Labour Force Survey (2002) was used to provide denominator data, with comparisons made between rates for Scotland and the rest of the UK. RESULTS: In 2002-2003, 4043 estimated cases were reported from Scotland. Mental ill-health was most frequently reported (41%); followed by musculoskeletal disorders (31%), skin disorders (16%), respiratory disease (10%), hearing disorders (2%) and infection (1%). The reported average annual incidence rate per 100,000 employees for all work-related ill-health in Scotland was 86.0. The highest reported rate for mental ill-health was found for employees in public administration and defence (76.7 per 100,000), and health and social work (72.3 per 100,000). The construction industry had the highest reported rate of musculoskeletal disorders (41.6 per 100,000), while hairdressers appeared at most risk of developing occupational contact dermatitis (rate=86.4 per 100,000). CONCLUSIONS: Despite its limitations, THOR has indicated types of work-related ill-health and related industries for targeted disease prevention in Scotland.     

Fitness for work: the need for conducting a job analysis

Ensuring that employees are both physically fit for work by matching their capabilities with the physical requirements of their job, and physically fit for life by promoting health-related physical activities, are important and under-utilized tools in a company's arsenal for reducing absence and ill-health retirement (IHR). Both the Health and Safety at Work Act (1974) and the Disability Discrimination Act (1995) require evidence-based approaches to setting physical and medical employment standards. Proven fitness-related strategies include redesigning the most demanding tasks, selecting and training personnel who possess the necessary physical attributes, and assessing and redeploying personnel to jobs within their capability. An essential precursor to pursuing these strategies is to conduct a job analysis to quantify the physical demands of the job.     

Report of a system for diagnosis, categorizing and recording occupational mental ill-health

BACKGROUND: UK statutory systems for occupational disease recording do not include mental illness resulting from occupational stress. The issue is included within physician reporting systems, but there is no agreed set of criteria for diagnosis of occupational causation and no agreed system of categorization in terms of type of causation by workplace factors. METHOD: A multidisciplinary group of occupational health professionals, in conjunction with human resources staff, developed a system for the diagnosis, categorization and recording of occupational mental ill-health. RESULTS: The developed system was applied as a pilot and the outcome from its first year of use is presented. CONCLUSIONS: The system is considered to have operated well in pilot, and has now been adopted as a standard operating procedure by the occupational health provider who developed it. The system is proposed as a tool in the development of standardized NHS or UK national systems for the recording of occupational mental ill-health.     

Toothless tests: associations between the results of routine screening medical examinations and ill-health retirement of firefighters in west central Scotland

The final routine medical examinations (RME) of 526 full-time firefighters, all male, retiring from Strathclyde Fire Brigade in the decade beginning 1 January 1985 were studied to determine differences between the results of the 328 taking ill-health retirement (IHR) and the 198 completing maximum service (MS). Mean ages at IHR and MS were 48 and 54 years/respectively. This was statistically significant (P = 0.0000), so the results of the third RMEs, performed after the subjects' 46th birthdays, were also analysed. The findings were also reduced into quinquennia. Since the RMEs were weighted towards cardiovascular disorders, the outcomes of the 37 IHRs from arterial disease were sought and compared to the final results of those with MS. In both final and third RMEs, those completing MS were more likely to be non-smokers (60.9 vs 41.4%; 51.6 vs 42.6%; P = 0.01 and 0.015). In the final RME, subjects with MS generally had normal lung function (abnormal results 4.8 vs 10.4%; P = 0.002), abnormal chest X-rays and near vision (22.4 vs 7.6%; 91.1 vs 51.6%; P = 0.000 for both). In the third RME, firefighters with IHR were more likely to have hypertriglyceridaemia (39.6 vs 22.4%; P = 0.004), and reduced distance vision (32.2 vs 21.2%; P = 0.03). Where IHR resulted from arterial disease, sufferers had raised mean cholesterol (6.76 vs 6.20 mmol/l; P = 0.049), raised median triglycerides (2.1 vs 1.55 mmol/l; P = 0.0236), hypertriglyceridaemia (44.4 vs 21.2%; P = 0.008) and less likely to be non-smokers (32.4 vs 60.9%; P = 0.001). Differences between body mass index, systolic and diastolic blood pressure, fasting and HDL cholesterol, electrocardiogram abnormalities, urinary abnormalities and total numbers of risk factors did not reach statistical significance, apart from isolated quinquennial episodes. These results suggest that, except for highlighting known health hazards, current RMEs are ineffective in identifying those at risk of ill-health retirement in this group.     

Hearing loss, accidents, near misses and job losses in firefighters

BACKGROUND: The hearing losses of workers exposed to occupational noise have been extensively documented, but no information exists on the level of hearing loss which results in job loss. AIM: To define levels of hearing loss associated with ill-health retirement (IHR), comparing them with existing standards and assessing the extent to which poor hearing contributes to accidents and near misses to assist the development of rational standards for retention. METHODS: All UK local authority fire brigades were approached for information on IHRs due to audiological problems, accident/near-miss totals and the numbers thought to be due to poor hearing in a 60-month period beginning in 1997. RESULTS: Only 15/59 (25%) of brigades provided all information requested, although 50 (85%) and 32 (52%) supplied medical and safety information, respectively, which was used for analysis. Of 3366 IHRs, 135 (4%) were due to audiological problems. When compared to a control group of firefighters of similar age, those taking IHR had worse mean and median hearing losses in all grouped frequencies in both ears than the controls, and this difference always reached statistical significance (P < 0.001), but there was considerable overlap in terms of range of hearing loss in each group. Only 41/31 274 (0.13%) of accidents/near misses reported were believed to result from hearing problems, and seven of these were related to device failure. CONCLUSIONS: Retention criteria based on audiometric grounds alone may result in unnecessary IHRs. Poor hearing is only responsible for a small proportion of accidents and near misses.     

Changing medical criteria and medical severance payments may reduce the rate and costs of ill-health retirement

OBJECTIVES: To identify the core best practice standards in ill-health retirement (IHR) procedures. To investigate whether changing medical criteria and introducing medical severance payments affect the rate and cost of IHR. METHODS: The core standards for best practice in IHR procedures were distilled from the published literature. On 1st April 2000 the study pension scheme altered the IHR medical criteria to define permanent incapacity and introduced medical severance payments for employees with temporary incapacity. Rates and costs of IHR were measured before and after these changes. RESULTS: Following the changes, the annual rate of IHR fell from 8.89 to 2.90 per 1000 members (P < 0.001), the median age at IHR rose from 50 to 55 years (P = 0.01) and pension scheme costs fell by 25 million pounds sterlings per year. CONCLUSIONS: Changing medical criteria and introducing medical severance payments may reduce the rate and costs of ill-health retirement. Target rates of four cases of IHR per 1000 active members per year, and 15% of total retirements, are proposed for schemes serving industries with average health risks.     

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.     

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.     

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.     

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.     

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.