Shared learning database

NHS Camden Provider Services Occupational Health Service
Published date:
February 2011

Depression and anxiety are common barriers to return to work of staff absent on long term sickness absence (LTSA) i.e four consecutive weeks or longer. Motivated by participation in the National Audit of depression detection and management of staff on long term sickness absence (Health & Work Development Unit, RCP) we have overcome barriers to improve our Occupational Health Service performance. Our service assessment of depression improved from 55% (58% National Audit round one average) to 90% (67% National Audit round two average). We have also created a clear clinical pathway to guide clinicians on client self help information, advice on treatment options, onward referral for physician assessment and guidance on review. The example is relevant to NICE CG91, PH19 and CG90.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

- To improve detection of depression and anxiety in LTSA cases. - To devise a care pathway for those found to have anxiety or depression. - Overcome the barriers that prevent Occupational Health clinicians following agreed procedures . - To add depression and anxiety screening questions to the OH standard assessment form. - To select a validated tool to assess depression and anxiety for use in OH assessments for cases identified by using the screening questions. - To develop a pathway for appropriate clinical care, that includes client self help information advice on treatment options , referral on for physician assessment and guidance on review. - To reduce the mental health barriers to return to work. - Effective training for clinical staff. - Audit of new procedure.

Reasons for implementing your project

Psychological ill health accounts for about 30% of sickness absence in the NHS, but it is also known to co-exist with physical health problems and to be a barrier to the return to work of staff with long term sickness absence. It is therefore important to ensure that Occupational Health assessments include mental health assessment so that action can be taken at an early stage. In our Occupational Health Service (OHS) the medical staff had received detailed training in mental health assessment and had delivered general training to the OH Nurse Advisors ( OHNA), none of whom had mental health nursing as their basic qualification before their specialist OH training. A standard assessment form for referrals to Occupational Health had been developed as a quality improvement. However this form did not have standard enquiry about mental health above a broad question 'How are you feeling today?'. More specific mental health enquiry was left up to the judgement of the clinician. Our OHS had been previously successful in implementing a standard assessment of low back pain in line with national guidance, and had gained experience in overcoming the barriers to change. Participation in the first National Audit of depression detection and management of staff on long term sickness absence in 2008 showed average results for our OHS ( 55%) in comparison with national data ( 58%)in screening of LTSA cases for depression whatever their underlying diagnosis. This motivated the OHS to target improvements in the detection of depression and anxiety in long term sickness absence cases and to develop a care pathway to optimise their management.

How did you implement the project

The two OH specialist doctors met as a project group. Time was allocated to the project. The first step was a review of tools for the assessment of mental health which led to the choice of the NICE recommended, two screening questions for depression and the Hospital Anxiety and Depression Scale ( HADS) for use with clients found to be screen positive. No validated screening questions were found for anxiety, so the clinicians devised two questions. HADS was already known as a useful tool to the OH clinicians but seldom used. This was confirmed by an audit of the use of HADS in the OHS. It was found that it was used in 10% of management and self referrals mainly by one OHNA. This audit was discussed at a departmental clinical team meeting and the OHNA gave feedback about the need for training and a clinical pathway. The HADS clinical pathway was developed: All new management and self referrals were to be screened for depression and anxiety with the standard assessment form modified to include the specific screening questions - HADS performed if screen positive - Function was also assessed including time off work in the OH consultation - HADS score 8-10: self help information given, consider referral for counselling or to OH clinician with training in CBT approach, review and onwards referral - HADS score 11-21:enquiry about further symptoms of depression, self help information, consider referral for counselling or to OH clinician with training in CBT approach and refer on to OH doctor. Training was delivered to the OH clinicians on depression, anxiety, HADS and the HADS pathway and self help information for clients including on line CBT. Discussion took place at the meeting about the practicalities of asking the screening questions and the completion of HADS. One to one training for individual cases also occurred on an ad hoc basis, either at the instigation of OHNA seeking further advice or from the OH doctor giving feedback on cases referred by the OHNA.

Key findings

Eight months later an audit of the HADS pathway was performed. The OHS standard assessment form was used in 70% of cases, and the screening questions were asked in 47% of cases. Of these 63% were screen positive, and 60% had HADS performed. The updated assessment form with the screening questions had not been used in some of the cases therefore the clinician had not had the prompt to ask the screening questions. These results were disappointing and discussed at the team meeting, with some further training for OHNA. One action from the meeting was to ensure that a member of the administrative team did weekly checks that the standard assessment form and HADS were available in all consulting rooms. Around this time an opportunity arose to work with a computer company to modify a self service programme for clients to complete in the waiting room before their consultation. This system includes self entry of HADS. Through this development stage all clinical staff were involved in testing the programme and giving feedback on improvements. This has nudged understanding further in the OHS that assessing mental health in each consultation is the norm not left to the discretion of the clinician. In May 2010 the OHS participated in the second round of the National Audit depression detection and management of staff on long term sickness absence which collected data on cases between January and August 2010. The results of this audit sent to OH in January 2011 have shown that 90% of LTSA cases assessed by our OHS were assessed for depression. The national result was 67%. Our OHS had therefore shown an improvement of 35% compared with the national improvement of 12%.

Key learning points

- Motivation: o The prime motivation for this project came from participation in national audit. o The regular meetings between the two OH doctors to discuss progress helped to drive the project on as did protected project time. o Results of audits were presented at team meetings o The team gained motivation from being involved in discussion of changes to processes and standard forms, having their contributions valued and their concerns and training needs listened to. - Awareness, knowledge and skills: o Training involved different styles, presentation, group discussion and 1:1 training so that it was accessible to all clinicians. o Training was also given to OH clinicians not present on the day of the team meetings. o The OHS has a culture of training and a training champion who assists individuals to meet their statutory and personal development plan training needs. There is also a firm commitment to audit within the department with each clinician performing their own audit projects. - Practicalities: o The practicalities of changing the assessment form were helped by easy network access on the computer system and the removal of old forms o by support from the administration staff in ensuring the availability of the forms. - Acceptance and beliefs: o The OH clinicians accepted the change in the assessment because at the original discussion, following the early audits, they expressed a training need and a need for a clear pathway. Once they started using the new system finding clients with depression or anxiety reinforced the process. - Outcome: o A clinical pathway developed and agreed for identified cases o This was set out as a algorithm for easy reference.

Contact details

Judy Sharpey-Schafer
Associate Specialist Occupational Health
NHS Camden Provider Services Occupational Health Service

Is the example industry-sponsored in any way?