Pennine Acute hospitals NHS Trust
Pennine Acute Hospital NHS Trust, continuing the momentum set by Dame Carol Black and Dr Stephen Boorman in their recent reports, aims to reduce sickness absence from 18 to 8 days/employee/year and expects Occupational Health(OH) to play a key role by targeting obesity in staff thereby reducing disability, premature retirement, work stress and injury whilst improving work attendance and productivity.
Current obesity management in OH is inconsistent with no set protocol and muddled care pathways, yet NICE has produced in CG43 a systematically developed framework to promote high quality evidence-based assessment and management of obesity. An audit was performed to identify deviations in OH practice from recommendations in CG43, design an action plan to correct deficiencies bringing clinical staff up-to-date with best practice, to ensure a consistent standard in diagnosis and management of obesity and also to dispel the current apathy in OH which surrounds the subject of obesity.
Guidance the shared learning relates to:
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
1) To perform an audit of baseline compliance of Pennine Acute Hospitals NHS Trust (PAHNT) and its Occupational Health (OH) Department's policy and practices with recommendations of the NICE Obesity Guidance (CG 43) with regard to awareness and management of overweight and obesity in staff.
2) To identify areas of non compliance with the Guidance, uncover deficiencies in performance and introduce an action plan to revise practice in Occupational Health and ensure consistent standards in the diagnosis and management of obesity.
3) To reduce obesity in staff, thereby improving their health and well-being, work attendance and productivity, reducing disability, job stress, early retirement and risk of injury on duty. Additional benefits would be higher levels of patient satisfaction and overall improvement of local population health.
1. To measure if Trust policies and Occupational Health practices for management of obesity in staff comply with the recommendations of the NICE Obesity Guidance (CG 43).
2. To design an Action Plan to correct deficiencies, bringing Occupational Health clinicians up to date with best practice and ensure a consistent standard for diagnosis and management of obesity within a set time frame for improvement.
3. To use the audit to motivate and educate staff enabling a thorough understanding of obesity and its relevance to the workplace. Management of obesity cannot be seen in isolation from the obesogenic working environment where staff spend ¼ of their lives and in which they consume ½ their daily calories. Pressure and demands of work affect eating and activity habits.
4. To develop contacts between Occupational Health and key stakeholders within the Trust responsible for implementation of CG 43 for staff.
5. To ensure compliance with mandatory Standards for Better Health (Department of Health Developmental Standards D13 and C5)
6. To ensure legal compliance; since the NHS Reform and Health Care Professions Act 2002, NICE Guidance may determine the expected standard, the benchmark of clinical care in cases of medical litigation.
7. Ultimately, to reduce levels of obesity, with its consequent morbidity and mortality, among staff, thereby reducing disability, risk of injury at work and premature retirement whilst improving work attendance and productivity. This reflects the Trust's Health and Well-Being strategy to reduce sickness absence from 18 to 8 days per employee per year and continues the momentum set by Dame Carol Black and Doctor Steve Boorman in their recent reports. Occupational Health are expected to play a key role in implementing the Trust's Health and Well-Being strategy and Action Plan and thereby target Trust resources more effectively.
Reasons for implementing your project
PAHNT provides services to 1m people and employs 10,000. In the UK in 2008 25% of people were defined by internationally accepted criteria as obese. Staff face the same health issues as the wider population. With an index of 004 on the Deputy Prime Minister's Index of Deprivation 2004 ,North Manchester is an area of socio-economic deprivation with which obesity positively correlates. Life expectancy is 4 years less than the national average.
At 4.2% in 2008, the North West had the highest worktime/year lost in the UK with NHS sickness absence higher than anywhere in England, and average sickness days per Trust employee 18.4/year (rest of UK 10.7). At 5.8% in 2009 PAHNT sick leave ranked as very poor on the Boorman Scale - a measure of sick leave relative to health and wellbeing status. Direct cost was £11,261,000.
Obesity, at 25% among staff, is a significant factor in sickness absence and should be accounted for in risk assessment. Poorer ergonomics, compromised manual handling, ill-fitting personal protective equipment, termination of duties, resignation, injury/death at work and premature retirement all correlate with obesity.
Research supports the link between sick leave and obesity. Typical obesity related diseases leading to OH referral are type 2 diabetes, hypertension, ischaemic heart disease, hip and knee osteoarthritis, low back pain, depression, sleep apnoea, asthma, gallbladder disease, infertility and work stress.
PANHT aims to reduce sickness absence to 8 days/employee/year saving £7m in sickness absence related bank and agency spend by adopting the Boorman Report principles in their Health and Well-Being strategy. Reducing obesity in staff using better informed OH Services is a key target.
Establishing a system in OH for assessment and management of obesity in staff based on the high-quality systematically developed framework in CG 43 will ensure OH meets these expectations as well as complying with mandatory standards.
How did you implement the project
1. Attended Boorman workshops; joined Strategic Group of Health and Wellbeing Committee
2. Instigated OH training event introducing CG43; questionnaired staff on knowledge/training
3. Precised CG43, defined standards, criteria, collecting tools for protocol registration with Audit Department
4. Permission from North-West Ethics Committee, Governance Department, OH manager
5. Collected data from
- Trust policies, minutes, NICE database
- OH staff questionnaires
- Managers interviews - Audit, Facilities, Catering, Transport, Dietetics, Health Improvement, OH
- Premises survey
- Pre-employment files of 300 staff seen by OH June 2010
Files of 50 staff at North Manchester Hospital with obesity seen June/July 2010
1. Closure of pre-employment medicals removed a relevant opportunity to assess obesity
2. Of 300 records only 160 had weight recorded
3. More time needed for data collection
4. CG43 is complex; defining recommendations specific to OH - measuring weight at health checks, obesity related diseases ? was difficult as was persuading clinicians of their relevance
5. Disinterest/inertia from clinicians, more so senior ones with other priorities
6. Referral avenues for dietary advice obscure - staff could not see Trust dieticians ? and no culture that recognised the need for such referrals
7. The 3 hospitals in the Trust had different obesity care pathways for staff; referral systems between PAHNT and Public Health Services were disjointed with staff awareness limited
8. Questionnaires of 20 OH clinicians uncovered other barriers
- 75% said time was major one
- 50% felt mentioning obesity risked alienating patients
- 45% disliked the unpleasantness obesity can present
- 50% declared obesity a low priority
- 45% feared opening a Pandora's box.
Costs: Audit was performed as part of training using extant resources - Audit Department - therefore cost free.
Descriptive statistics expressed as raw numbers and percentages and presented in tabular/chart form were compared to CG43 recommendations.
PAHNT had implemented CG43; improvements were suggested for cyclists, exercise facilities and low fat foods choices at hospitality events.
OH compliance was inadequate:
1) No plan to tackle staff obesity
2) OH staff training insufficient
3) Lack of furniture/equipment for assessment of obese patients
4) 75% of OH clinical staff said time was main resource barrier
5) Lack of posters/leaflets on healthy eating/exercise
6) Only 50% of the sample patients examined at routine health checks in 2010 had weight recorded and 0% waist circumference
7) <50% Trust staff with obesity had been given advice on multi intervention treatments
8) Inadequate assessment of risk (42%) and causes (62%) Cause in 90% was psychological distress
9) Reluctance to address obesity; 50% of OH clinicians declared obesity a low priority and feared alienating patients
Action plan: OH system for assessment and management of obesity
- Nominate lead OH consultant
- Train OH staff
- Equip OH department ;supply BMI Bundles containing relevant documents
- Set up weight management clinics for staff self-referral, assessment of obese staff with co-morbidities and NHS Plus service.
- Design obesity operating procedures translating CG43 into protocols for rapid obesity assessment /management in OH clinics and detailed appraisal in weight management clinics
- Set up database(document control centre, links to care pathways, research)
- Results and Action Plan presented to the Trust Health and Wellbeing Committee and OH clinicians
- OH Working Party 2012 to evaluate OH and Commercial Weight Management Clinics
- Evaluation of Standard Operating Procedures usage 2012
- Health and Wellbeing Committee to monitor reports from OH working party, sick leave and CQC staff survey 2012
- Repeat audit 2012
Key learning points
Pointers to Success
1) Decisive senior leadership - management and clinicians
2) Network via Health & Wellbeing Committee :commit key stakeholders eg Public Health
3) Enthuse and energise OH staff; stress obesity is a disease with significant morbidity and mortality not a lifestyle choice; avoid judgemental attitude (Resulted in unexpected weight loss in staff newly committed to Weight Watchers)
4) Reinforce project's relevance regularly at staff meetings
5) Give unequivocal responsibility to selected OH staff to manage the clinical and reception areas to ensure correct equipment and information is maintained
6) Use sensitive clear language to address the difficult topic in clinics eg How do you feel about your weight at this time?
7) Engage a multidisciplinary approach as stressed by CG43 eg OH Weight Management Clinics on all Trust sites, Weight Watchers, NHS Why Weight Programmes
8) Maintain momentum: an OH working party - Manager/Consultant/Nurse - responsible for obesity to meet often with Health Improvement Manager to progress Action Plan.
-Burdening lead clinicians with detail
-Complexity. Time is key barrier: once the moment is lost in clinic the clinician is unlikely to get another so a simple coherent system - referral forms, patient information leaflets, telephone numbers all immediately to hand - is key to ensure good outcomes
-The obesity word - use alternatives eg BMI, weight management
-Denial of obesity's significance. Because of its prevalence there is resistance to accepting it is disease. Frequently Trust staff with BMI >30 have not had their disease addressed perhaps because of extra work involved referring to their GP or organising a care pathway. Obesity is not approached by clinicians the same way as other chronic conditions - culture change in the profession is needed.
Specialist Registrar Occupational Medicine
Pennine Acute hospitals NHS Trust
Is the example industry-sponsored in any way?