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THE OFFICIAL MAGAZINE OF iOH Volume 28 Issue 1

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Spring 2021

OH TODAY

Book a place on our upcoming webinars

OH TODAY Spring 2021

Partners of OH Today

Editor LYNN PRATT

Assistant Editor

CONTENTS From the President

Long COVID: The Next OH Challenge

Back to School: MSK Health for Early Years and Primary Teachers

Dozing Off: The Dangers of Sleep Apnoea

Cauda Equina Syndrome

The Use of Assessment Tools in OH

Getting Recognised: SEQOHS Accreditation

Interview: Janet O’Neill

Professional Diploma in Travel Health - Course Review

JANET O’NEILL

Production Editor HAMISH PRATT

Copyright © iOH 2021 Published by iOH, The Association of Occupational Health and Wellbeing Professionals ioh.org.uk email: admin@ioh.org.uk Views expressed in OH Today are those of the contributors and not necessarily those of the iOH. Nor does iOH necessarily endorse any products or services mentioned or advertised in the publication.

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From the President Neil Loach

t’s that time in the year when we are all getting ready for spring and the summer holiday booking season begins. Not that we are going to be able to plan much in terms of holidays for this year and things start to develop into some kind of normality. Normality that is not yet known but certainly wished for. In terms of iOH, we are continuing to develop our range of services and commitments to members for this year. We have seen the hugely successful launch of 21 for 2021 webinars and these have regularly “sold out” really quickly, although some members were not able to take up their booked place for a variety of reasons. You can book a place for future webinars as well as catch up with recording of previous ones on our website.

The past year has put OH Practitioners under great stress and has alienated us all from our normal working patterns and sources of support

We have just reviewed our corporate aims and objectives and our constitution which were passed unanimously at the Extraordinary General Meeting held recently. Our changes were only minor, related to membership categories, board positions, and what happens in the event of dissolution of the Association. One of the amendments relates to the creation of a new board position and as a result of this I am delighted to welcome Danny Clarke as the iOH Director of Occupational Safety & Hygiene. Danny has a huge range of experience in the field of Occupational Health & Safety and is a Chartered Member of IOSH. We are also looking to recruit a Director of Social Media and External Communications. Please watch this space for any future exciting announcements.

OH TODAY Spring 2021

Over the next year, iOH is looking to set up a number of working groups to look at various topics. The first working group will look at transgender issues in the workplace. They will aim to develop guidance on how to deal with these issues with compassion and within the framework of the Equality Act (2010). This is a potential issue for our clients, patients and workers in relation to the provision of Occupational Health Services and the complexity that health surveillance — particularly respiratory surveillance — can bring in their declared gender. If you would be interested in joining this group, please email admin@ioh.org.uk. Christina Riley who hosted our recent iOH webinar on this topic has agreed to be our Subject Matter Leader for this project. We are also going to be running a survey in the coming months regarding the appetite for clinical supervision within Occupational Health how iOH could help to facilitate this. The past year has put OH Practitioners under great stress and has alienated us all from our normal working patterns and sources of support. We need to address these issues and try to bring about that sense of support and the new normality for our members wherever possible. Please keep safe, consider taking the vaccine, if you haven’t already, and if you are an independent practitioner or working for a provider, you can register for it online. Take care and enjoy this quarter’s edition of OH Today. Neil Loach President, iOH ⬛

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A G L O B A L L E A D E R I N R E S P I R Aioh.org.uk T O R Y DOH I ATODAY G N O S T I5C S

OH TODAY Spring 2021

OVID-19 has had a significant impact on all areas of our lives, with the socio-economic impact likely to be felt for many years to come. The rapidly changing situation regarding testing, clinical vulnerability and vaccination has kept OH Practitioners on their toes, and it has been heart-warming to observe the sharing of knowledge and best practise within the OH community as a result. While we know that most people who get the disease will experience mild to moderate symptoms and make a functional recovery, there are a number of individuals who are experiencing long term health issues affecting their attendance at work. Increasingly they are being referred to OH for our advice on their fitness for work and the need for workplace adjustments. Our latest challenge is providing evidence-based advice when our understanding and knowledge of this new condition is constantly evolving. As already highlighted, most individuals who develop symptomatic COVID 19 will make a functional recovery within 2-4 weeks. Approximately 20% may experience a slightly longer recovery period, experiencing issues with post viral fatigue and cough, that gradually resolves with rest and graded exercise within 12 weeks.1,2 However there are estimates of between 1 – 10 % of patients, who appear to be experiencing much longer-term symptoms.2,3,4 Certainly, I have started to see clients in my clinics who, 6-10 months on from their initial infection, continue to experience significant health issues. The term Long COVID was initially conceptualised by patients, who found each other through social media and lobbied for recognition, further research and support due to their ongoing symptoms. The term was eventually adopted by the media and clinicians to define a range of symptoms commonly

being experienced by patients 12 weeks post infection.5 While NICE acknowledges the term, it uses definitions on page 8, which would probably be best practice for OH to adopt. We know that critical illness such as sepsis and other conditions that may require ITU care, can result in a range of long-term symptoms, commonly given an umbrella term of Post Sepsis Syndrome (PSS) or Post Intensive Care Syndrome (PICS).7.8 The World Health Organisation, Sepsis charities and researchers in several countries have highlighted the similarities between the range of symptoms of these 2 syndromes and the long-term symptoms being reported post COVID. Some have even gone as far as suggesting that Post COVID-19 Syndrome is in fact a result of viral sepsis1,9.10. The UK Sepsis Trust highlights on its website, that symptoms such as breathlessness and fatigue tend to gradually improve over a 6-to-18-month period.7 Although others are reticent to attribute Post COVID symptoms to a single cause11. Only time will reveal if recovery follows the same path for sepsis caused by other infections, or if there are additional unique health issues experienced due to COVID -19, but it gives us a base from which to start. One small study highlighted that 55% of post COVID patients had three or more symptoms, with the most common being extreme fatigue, breathlessness, joint and chest pain.12 In addition, symptoms do not appear to be dependent on the severity of the initial infection and can be relapsing and remitting in nature.2 Due to the aggressive inflammatory response and increased risk of blood clots that the infection can cause, there have been cases of associated coronary heart disease, heart attack, stroke, Pulmonary Embolism (PE), kidney disease and new onset of diabetes, although these complications are rare.2,13

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Post-COVID Definitions Acute COVID-19 Signs and symptoms of COVID‐19 for up to 4 weeks.

Long COVID In addition to the clinical case definitions, the term 'long COVID' is commonly used to describe signs and symptoms that continue or develop after acute COVID‐19. It includes both ongoing symptomatic COVID‐19 (from 4 to 12 weeks) and post‐COVID‐19 syndrome (12 weeks or more).

Source: NICE6

Although advising on this new disease is daunting, we have the existing knowledge and skills to be able to support employees and management. We already assess the functional impact of the symptoms outlined above and offer advice regarding their impact on workability and appropriate adjustments. This is because these symptoms are not unique to COVID-19. We can utilise the knowledge we have gained regarding conditions such as multiple sclerosis, fibromyalgia, chronic respiratory disease, cancer, stroke and traumatic head injury to inform our practise. Going back to basics and carrying out a good functional assessment, looking at the impact on activities of daily living, is a cornerstone of OH practice. The World Health Organisation (WHO) in

OH TODAY Spring 2021

their training package on COVID-19 rehabilitation, repeatedly advocates the use of well validated assessment tools to assess and monitor progress.1 The concept of fatigue and how it impacts on daily life is hard to describe. Therefore, assessment tools such as the Chandler Fatigue Scale (CFQ11)15,16 and the Fatigue Assessment Scale (FAS)17, can help us to assess the impact the fatigue is having on both physical and mental functioning, in a reliable and reproducible manner. The Medical Research Council (MRC) dyspnoea scale18 has long been used for grading the effect of breathlessness on daily activities, with a level 3 score being used as a criteria for further investigation and respiratory rehabilitation.19 Other specific assessment tools have

Source: Sepsis Trust⁷

Source: NHS14, NICE6 and WHO1 Shortness of breath, cough Chest pain or tightness Joint and muscle pains Insomnia Rashes Changes to sense of smell or taste Feeling sick, diarrhoea, stomach aches, loss of appetite Pins and needles A high temperature Anxiety and Depression Problems with memory and concentration ("brain fog") Heart palpitations Reduced kidney function Cardiac injury or disease Tinnitus, earaches and dizziness

been developed by various multidisciplinary COVID rehabilitation clinics and are included in the appendix of the NHS England guidance for post-covid syndrome assessment clinics.20 It is estimated that approximately 15 - 20% of people who develop COVID-19 symptoms will require hospital treatment, while 5% are likely to need intensive care13. This cohort of patients is the group that multidisciplinary rehabilitation services are predominantly targeted at. However, as many individual’s with post COVID symptoms will not have been hospitalised or have had limited contact with primary care services, we may provide their first in depth interaction with a health care professional. This gives us chance to really add value by helping them to learn to mitigate the impact of their symptoms and aid rehabilitation, by highlighting available techniques, signposting them to patient education materials and referring them to

Lethargy/excessive tiredness Poor mobility / muscle weakness Breathlessness Chest pains Joint and muscle pains Insomnia Hair loss, dry / flaking skin and nails Taste changes / Poor appetite Changes in sensation in limbs Feeling cold/ Excessive sweating Anxiety and Depression Issues with concentration and short-term memory PTSD (Post Traumatic Stress Disorder) Mood swings Swollen limbs Reduced kidney function Repeated infections from the original site or a new infection Changes in vision

rehabilitation services or primary care, as appropriate. For example, highlighting the importance of avoiding over exertion resulting in prolonged periods of rest (Boom and Bust type scenario), as this is not thought to be helpful. Instead taking the 3 Ps approach, planning activity to be as efficient as possible e.g., using equipment to reduce the effort required to carry out a task, does it need to be done today, can it be delegated. Prioritising the most important or demanding tasks to when the individual feels the most refreshed. Pacing activity to available energy, i.e., carrying out short periods of activity but taking a rest, or alternating to less demanding tasks, before exhaustion hits. Many people are trying to speed their recovery up by pushing their activity. I have been using the analogy of a broken bone: it takes time for the body to heal;effort and will are not necessarily going to speed recovery. Instead, adopting a graded

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approach to gradually increasing activity is likely to be of more benefit.2,21

• •

Experiencing breathlessness can understandably cause anxiety. However, as with back pain, there are suggestions that fear avoidance behaviour can prolong recovery.2,21 Using breathing exercises and posture can reduce the effort required and make breathing easier. Deep breathing and pursed lip exercises can help with anxiety, paced breathing can help meet the demands of exertion, while controlled breathing techniques may reduce breathlessness. However, as with back pain, there are some potential red flags due to the increased risk of cardiac conditions and PE. If patients feel severe shortness of breath that does not improve with positions and breathing techniques, then further medical assistance should be sought. I am not advocating we as OH professionals teach these techniques, as for most of us this will be outside our area of expertise. However, having an awareness of them can be helpful. The WHO have created a free online e-training package on post COVID rehabilitation and an associated patient guide which covers these techniques in more detail.2 There is also the NHS ‘your COVID recovery’ website, which is a good resource to direct employees to.21 Managers and HR are looking to Occupational Health for guidance in order to help them manage their workforce. Indeed, some in the HR sphere have already identified the significant impact Long COVID is likely to have on a large cohort of the workforce, and that they need to start taking into consideration how they might need to review sickness absence policies on rehabilitation, phased return to work and redeployment, to accommodate this.22 Adjustments for fatigue and breathlessness may include: •

Phased return may need to be extended if fatigue is a limiting factor.

OH TODAY Spring 2021

• •

• • • • • •

3 Ps- Planning, Prioritising and Pacing activity. Equipment to reduce effort required. E.g., trolley in order to avoid a boom and bust type scenario. Flexible working, to facilitate rest breaks, working when feels most refreshed. Homeworking, so energy is not expended on the commute. Reduced workload or targets Off peak travel / reduced travel around site Preferred parking Redeployment to a less demanding role Consider impact if a safety critical role.

Cognitive issues might include difficulty: filtering out background noise, being easily distracted, moving from one task to another, processing information quickly or with a poor short-term memory. Adjustments for these may include: • • • • • • •

Do not disturb sign / out of office for dedicated periods when need to focus. Quiet place to work or use of earphones. Checklists Digital reminders Doing one thing at a time Flow charts Write notes or use a digital recorder rather than hold something in the mind.

From an OH perspective, although this is a new condition, collectively we have a wealth of knowledge and experience on which to draw. Hopefully, ongoing studies that are tracking patient’s symptoms, treatment and progress will advise our practise in the future. However historically, when there is no definitive answer, we have as a specialism discussed and debated to come to a consensus opinion. I hope at least, this article can perhaps be a starting point for that discussion. ⬛

References 1.

World Health Organisation (2020). Course 6: Clinical management of patients with COVID-19 - Rehabilitation of patients with COVID-19. Accessed at: https://openwho.org/ courses/clinical-management-COVID-19rehabilitation. [Accessed 12.02.2021] SAGE (2021). Independent SAGE report on Long COVID. Available at:https:// www.independentsage.org/wp-content/ uploads/2021/01/Long-COVID_FINAL.pdf [Accessed 17.02.2021]

www.bmj.com/content/371/bmj.m3981 [Accessed 12.02.2021] 12. Carfì A, Bernabei R, Landi F,Gemelli. (2020) Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute covid-19. JAMA2020;9. doi:10.1001/ jama.2020.12603. pmid:32644129 13. Public Health England (10.02.2021) Guidance: COVID-19: epidemiology, virology and clinical features. Available at: https:// www.gov.uk/government/publications/ wuhan-novel-coronavirus-backgroundinformation/wuhan-novel-coronavirusepidemiology-virology-and-clinical-features. [Accessed 12.02.2021]

COVID Symptom Study, Kings College London (June 2020). How long does COVID 19 last? Available at: https://covid.joinzoe.com/ post/covid-long-term. [Accessed 13.02.2021]

Sudre CH, Murray B, Varsavsky T, et al. (2020). Attributes and predictors of longcovid: analysis of covid cases and their symptoms collected by the Covid Symptoms Study app. MedRxiv [preprint]. Accessed at: https://www.medrxiv.org/content/ 10.1101/2020.10.19.20214494v1 [Accessed 13.02.2021]

14. NHS, (February 2021) Long-term effects of coronavirus (long COVID) - NHS (www.nhs.uk)

Perego E, Callard F, Stras L et al. Why the Patient-Made Term 'Long Covid' is needed. Wellcome Open Res 2020, 5:224. Available at: https://doi.org/10.12688/ wellcomeopenres.16307.1 [Accessed 12.02.2021]

16. Craig Jackson, The Chalder Fatigue Scale (CFQ 11), Occupational Medicine, Volume 65, Issue 1, January 2015, Page 86, https:// doi.org/10.1093/occmed/kqu168 [Accessed 20.02.2021]

NICE, (December 2020). Guidance: COVID-19 rapid guideline: managing the long-term effects of COVID-19. Available at: Overview | COVID-19 rapid guideline: managing the long-term effects of COVID-19 | Guidance | NICE. [Accessed 12.02.2021]

The UK Sepsis Trust. [Online] Post Sepsis Syndrome Available at: https:// sepsistrust.org/get-support/support-forsurvivors/post-sepsis-syndrome/ [Accessed 20.02.2021]

Society of Critical Care Medicine (2013) [Online] Post Intensive Care Syndrome. Available at: SCCM | Post-intensive Care Syndrome (PICS) [Accessed 20.02.2021]

Prescott HC, Girard TD. (2020) Recovery From Severe COVID-19: Leveraging the Lessons of Survival From Sepsis. JAMA. 2020;324(8):739–740. doi:10.1001/ jama.2020.14103

15. Chalder Fatigue Scale: Available at: http:// www.goodmedicine.org.uk/files/ assessment,%20chalder%20fatigue%20scale.p df [Accessed 20.02.2021]

17. WASOG [Online] Fatigue Assessment Scale (FAS). Available at: https://www.wasog.org/ education-research/questionnaires.html [Accessed 20.02.2021] 18. Medical Research Council [Online] MRC Dyspnoea Scale. Available at: https:// www.pcrs-uk.org/mrc-dyspnoea-scale [Accessed 20.02.2021] 19. Bestall JC, Paul EA, Garrod R, et al. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease Thorax 1999;54:581-586. Available at: https://thorax.bmj.com/content/ 54/7/581.info [Accessed 20.02.2021] 20. NHS England. National guidance for postcovid syndrome assessment clinics. Nov 2020. Available at: https://www.england.nhs.uk/ coronavirus/publication/national-guidancefor-post-covid-syndrome-assessment-clinics/ [Accessed 13.02.2021]

10. Sepsis Organisation [Online] Post Sepsis Syndrome. Available at: https:// www.sepsis.org/sepsis-basics/post-sepsissyndrome/ [Accessed 20.02.2021]

21. NHS, (2020) [Online] Your Covid Recovery. Available at: https:// www.yourcovidrecovery.nhs.uk/what-iscovid-19/. [Accessed 12.02.2021]

11. Mahase E, (2020). Long Covid could be four different syndromes, review suggests BMJ;371:m3981. Available at: https://

22. https://www.peoplemanagement.co.uk/longreads/articles/should-hr-worried-longcovid#gref [Accessed 12.02.2021]

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Back to Musculoskeletal Health and Wellbeing for Early Years and Primary Teachers

s occupational health professionals, we are often familiar with anecdotal evidence through education networks about musculoskeletal disorders (MSDs) experienced at work. Working in low-level “child height” environments, together with the added factors of budget restrictions, pupil academic targets, limited understanding of healthier working practices, and leadership resistance to change in some schools – in addition to teaching and caring for children in a pandemic perhaps explains why little consideration is given to the importance ergonomics, school design, principles of posture and safer moving and handling. However, we know that supporting good musculoskeletal health underpins a person’s ability to live and work well and how it is fundamental to healthy aging, quality of life, and independence beyond working years. As professionals, we have an opportunity to be creative in our thoughts and approach and it gives us a great opportunity to support improvements in health and wellbeing for both staff and children.

OH TODAY Spring 2021

The Covid-19 pandemic has certainly raised employee health and wellbeing to the forefront of many leader’s minds. Studies suggest MSD complaints are frequently high among education sector workers globally, with perceived on-going MSDs up to 95%. 82% of early years teachers and teaching assistants experienced work-related MSDs at least once a week, yet only 8% had officially reported symptoms to their employer. We know direct and indirect costs of work-related MSDs to individuals, society (including healthcare systems) and organisations are vast. Additionally pertinent for the education sector is that there is a positive association between teacher wellbeing and pupil performance. Encouragingly, we know MSDs are preventable. This article gives a holistic approach to tackling MSDs in the early years and education workforce. By identifying risk factors and incorporating health and wellbeing as an integrated, collaborative approach, focused on health promotion and a culture of prevention, improvements can be made to musculoskeletal health which will benefit both staff and children.

o School

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Risk Factors and Effects of MSDs in Early Years and Primary Teachers Musculoskeletal disorders affect the body’s bones, muscles, joints, ligaments/tendons, and nerves. Various symptoms present depending on the pathophysiological mechanisms of the structures affected but symptoms tend to include: pain, fatigue, stiffness and restricted joint movement, sensory loss and numbness (including sciatica), and localised swelling. Low back pain, neck, and upper limb strain, and lower limb discomfort can be caused or exacerbated by workrelated activities. For example from: •

•

Uncomfortable working postures (including sitting on children’s chairs, bending over tables, kneeling prolonged standing, prolonged sitting, and during computer/VDU use. Working from home postures should also be considered) Awkwardly lifting and moving equipment and/or young children (during classroom activities, outdoor play, PE or transporting books) psychological issues (including workload, mental health at work, job demands, job satisfaction, conflicts at work, work-related stress, work-life balance.

MSDs associated with long-term health conditions, for example, pain, joint stiffness, and fatigue associated with rheumatoid arthritis, osteoarthritis, systemic lupus, fibromyalgia, osteoporosis, and ankylosing spondylitis can also be exacerbated by work. Additional risk factors to early years and primary teachers include: Physical inactivity - Physical activity maintains and improves strength and flexibility of the body’s muscles and joints, improves circulation and associated joint and muscle nutrition maintains and improves balance to reduce the risk of falls, and improves emotional wellbeing, all factors which contribute to musculoskeletal (MSK) health.

OH TODAY Spring 2021

Studies show an increased physical exercise in educators is associated with a lower incidence of MSD in the upper body and practitioners who increase the amount of exercise they undertake show a decrease in overall MSDs. Unhealthy working environment – A healthy workplace design and physical environment incorporates ergonomics, movement, areas for rest and considers noise, lighting, temperature, and air quality. It is a particular challenge to address the ergonomic requirements of adult workers, especially in low, “child-height” environments. A higher “perception of inappropriate infrastructures” (including noise, lighting, temperature, cleaning, ventilation, size, and furniture is significantly associated with higher MSD reporting in elementary teachers. Older age – Increased length of employment is a strong predictor of increased MSDs in teachers. It should be noted that teachers are working longer as retirement ages are increased. MSDs can begin in young workers with cumulative effects presenting later in life. High Body Mass Index – Being overweight increases strain on the body’s musculoskeletal system and being obese increases the risk of developing osteoarthritis of the knee. Maintaining a healthy weight with balanced nutrition assists body repair and bone health which helps prevent osteoporosis (and the risk of fractures) in later life. Vitamin D and Calcium Deficiency – Vitamin D and Calcium are required for bone health. Deficiency can result in reduced bone mineral density which increases the risk of fractures from falls (one of the most serious musculoskeletal problems in older people).

Smoking – In the general population, smokers and ex-smokers experience 60% more pain in the back, neck, and legs and a 114% increase in disabling low back pain. Smoking reduces bone mineral density, particularly among postmenopausal women. It is associated with more bone fractures and slower healing and associated with up to a 40% increase in the risk of hip fractures among men. Studies support a higher incidence of MSDs associated with smoking, in teachers MSDs can develop quickly or build slowly over time. Once developed they can adversely affect many aspects of life and can lead to absence from work. Mental and physical health are intertwined and MSDs and mental ill-health frequently coexist. People with depression are at a greater risk of developing back pain, depression is 4 times more likely in people with persistent back pain, and living with MSD pain can lead to feelings of anxiety and depression. Mental health also impacts a person’s ability to cope with and recover from MSDs. The majority of MSDs can be prevented, symptoms eased, and fully recovered from with early intervention, suitable treatment, and musculoskeletal health management (which incorporates occupational safety and health systems, leadership commitment, and employee participation).

• • •

•

Improved professional care and teaching to children Managing MSD risks in the education workforce

Managing MSD Risk in the Education Workforce Working with children is a physically and emotionally demanding role. Numerous, interrelating factors contribute to musculoskeletal health in early years and primary teachers. Risk assessment is about identifying and taking sensible measures to control risks in the workplace as low as possible.

82% of early years teachers and teaching assistants experienced workrelated MSDs at least once a week, yet only 8% had officially reported symptoms to their employer.

Additional benefits include: •

•

Fewer injuries to early years and primary teachers Reduced risk of work-related ill health and sickness absence Improved morale and reduced stress Improved staffing levels, attendance, and productivity

A hazard is something that can cause harm. A risk is the chance, however large or small, that a hazard could cause harm. Risk assessment should be carried out by someone who: • is competent to do so (has the right skills, knowledge, and experience) • involves workers and their representatives in the process • understands when specialist help or advice may be needed. Identify MSD hazards

Look for hazards that may result in harm. Employees, or their representatives, can give first-hand experience of what happens in practice; as can those working with children occasionally. Hazard mapping and body mapping, involving workers are useful adjuncts to risk assessment. Who might be harmed? Decide who might be harmed and how. This will usually be the teacher or teaching assistant, but

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Evaluate the risks Having identified the hazards, decide how likely it is that harm will occur. It is not always possible to eliminate risks but employers have legal responsibilities to do everything reasonably practicable to protect people from harm.

Early Int

Treat

Legis lat ion

it might also include children or visitors. Consideration should be given to groups who may be particularly at risk of MSDs, such as new starters, employees returning to work, those with pre-existing medical conditions, new and expectant mothers, or those working long hours.

MSD Man Return

Regula

Health and Safety Laws OSH Guidance

MSK H

Record your findings

Regularly review MSD risk assessment should be regularly reviewed to ensure continuous sustainability and long-term improvement. There is no set frequency for carrying out a review, but the risks to those who work with children, and others need to be suitably controlled. Changing circumstances may also prompt a review, for example, an increase in the number of children, changing ratios, or a reduced number of employees. If anything significant changes, a risk assessment should be checked and updated.

MSD Prevention Guidance for Early Years and Primary Teachers

Tr nd ge a Knowled

Significant findings should be recorded, focussing on prevention measures. Together with accident investigations and consultation with workers, changes to working practice can be identified with additional measures put in place to further reduce MSD risks.

School Leadership Teacher Training

OSH Education Network

ain ing

OH TODAY Spring 2021

Workplac Design Manual Handling Seating, furniture, equipment storage Technology Use Home Working

Physi cal

Ergon

Healthier working environment Seating, Furniture, and Equipment: • •

The following measures can help effectively manage MSDs in schools. It is useful to think of “Healthier working environment” and “Safer practitioner” for individual workplaces.

Teach Teaching

•

A range of safe, appropriate seating to meet the needs of the workforce is offered. Practitioner health and safety (ergonomics) is considered when purchasing new seating, furniture, and equipment. Seating, furniture, and equipment are in good working order and meets health and

nagement

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to Work

ar Review

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Storage: •

•

Workplace Design:

Emotional Wellbeing Workplace Culture

•

Mental Health Support Healthy Lifestyle Beliefs

Health

hers and Assistants

Sleep

Bone Health Diet

Physical Activity Light Noise Air Quality

tal n e m n Enviro

nomics •

• •

•

al th yL ifes tyle

Hydration

Furniture and equipment are safely stored with clear access to minimise practitioner lifting, carrying, and awkward postures. Mobile storage solutions are considered and used where possible.

safety requirements. Seating, furniture, and equipment are inspected and maintained at regular intervals, in line with the manufacturer’s recommendations and maintenance schedules. Manual handling equipment is provided and used appropriately by employees. Unsafe equipment is removed immediately from service and reported to a named contact.

• •

•

Employees have access to adult height desks and chairs for written/computer work and access to adult height sinks (or can use a washing up bowl in standing). Consideration is given to practitioners’ working postures with equipment provided to support low, “child height” working. Floors are even, unobstructed, and well-lit, and doorways (including storage areas) are accessible. Children’s independence is encouraged to access their own resources and equipment, especially at mealtimes to reduce lifting. Movement, rest breaks, and hydration are encouraged throughout the day. Timetabling allows as much time as possible for children to be independent and for fewer room changes for staff carrying resources. Employees are asked about their seating requirements and workstation/classroom setup. New design and build consultations include workplace health and safety needs of practitioners.

Safer practitioner Training: •

•

Regular, setting-specific manual handling training, which includes lifting and moving children in a range of situations and postural awareness for employees is provided. Employees and volunteers working regularly on a computer or mobile devices complete DSE training.

Knowledge: •

Teachers and teaching assistants are aware of MSD risks in their workplace and how to

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•

reduce them (in the classroom, outdoor learning, and at a computer). Practitioners know how to carry out routine safety checks on mobile and safety equipment and report any faults. Teaching and teaching assistants are competent and capable of doing their work in a way that is safe for them and other people. Practitioners know how to recognise and report early symptoms of MSD ill-health via a clear reporting system and are encouraged to do so by school leadership. Healthy Lifestyle advice is promoted and initiatives supported (e.g. active travel, physically active school challenges, healthy eating menus, workload recognition, sleep).

For MSD measures to be effective, trusted, proactive leadership is necessary with collaborative working within and between organisations. Additional early intervention and return to work advice can be obtained from occupational health and safety advisers. Importantly, research shows pre-existing MSDs can be carried into future workplaces having consequences for children, young people, and organisations.

Conclusion Workplace health has proven to be a successful business asset and strategy for improving the health of employees and quality of the working environment. Workplace health interventions for teachers and teaching assistants also improve learning experiences and educational outcomes for children and young people. Holistic MSD management requires an integrated approach recognising physical, social and emotional influences with a focus on prevention (with self-management) and early intervention. A collaborative, multidimensional effective approach includes: whole-school interventions promoting health, improved MSK health and ergonomics training of educators and school leaders, liaison with school designers and occupational health professionals to improve teaching and learning environments, MSD risk

OH TODAY Spring 2021

awareness, and healthy lifestyle engagement for education employees, together with health and safety education for children and young people. There is an enormous opportunity for greater, combined impact to tackle MSDs in the education sector. Data collection will be required to understand local needs and measure impacts. However, there is a genuine desire for healthy and successful teachers and teaching assistants, together with healthy and achieving children and young people. If you or others in your network are working in the early year’s sector, please consider taking part and sharing the University of Derby’s research link “MSK Health in the Early Years Workforce”

Useful Resources Awareness and Prevention of Back Pain and other Musculoskeletal Disorders in the Early Years Workforce Back care - awareness and prevention HSE – Musculoskeletal disorders European Network Education and Training in Occupational Safety and Health (ENETOSH) | Official campaign partners Better Schools by promoting musculoskeletal health - Safety and health at work - EU-OSHA Napo for teachers The LOcHER project Vision Zero Lorna Taylor is a Chartered Paediatric Physiotherapist working within early years and primary education settings. Lorna is an active campaigner for improved musculoskeletal health and wellbeing in the education sector. She is also the UK ambassador for ENETOSH (European Network for Education in Occupational Safety and Health) ⬛

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Written by Bernard Garbe Chairman, Vitalograph

The Dangers of Obstructive Sleep Apnoea 20

OH TODAY Spring 2021

ave you ever been in a meeting when one of your colleagues falls asleep? I think we all have and might consider it to be amusing unless you are in the chair. But putting on your occupational health hat, why is that individual dropping off? Chances are that it is due to sleep deprivation, but what is the cause? It could be very obvious, a new baby, perhaps. But it could be something more serious, a condition known as obstructive sleep apnoea (OSA).

Worker Effect OSA can have a significant effect on an individual’s work performance. One of effects of sleep deprivation is that innovative thinking and decision-making abilities are reduced. Sleep loss can impair an individual’s ability to make flexible decisions or quick rational judgements during an unforeseen crisis. Consider safety-critical occupations, for example individuals who spend the majority of their working time driving. Sleep loss can also affect an individual’s ability to recall facts quickly, and those deprived of sleep are less articulate, especially when vocalising thoughts. It also impairs their ability to provide novel answers quickly. Individuals suffering from sleep deprivation also have problems finding the right words and delivering ideas, their tiredness and fatigue impacts on their communication skills and impairs their team working – not to mention short tempers which can permanently damage working relationships. The effects of sleep deprivation on our ability to think, communicate and make decisions can affect every aspect of our

working life. Research into accident causation has found that in major disasters – such as the Exxon Valdez oil spill in 1989 – long working hours, coupled with a disturbed sleep pattern, contributed to a decision-making error. Difficulties in sustained alertness should be considered when undertaking health surveillance of workers in occupations where activities could be hazardous to individuals. Such workers can include airline pilots, air-traffic controllers, longdistance lorry drivers, and those who work with potentially dangerous machinery and processes. Those who are found to be at a high risk of reduced alertness should be suspended from duties until they start to respond to adequate treatment.

What Exactly is Obstructive Sleep Apnoea? Sleep apnoea can be defined as the cessation of breathing during sleep. There are three main types of intermittent apnoea during sleep: obstructive, central and mixed apnoea. However, OSA is the most common form. A person suffering from OSA will experience episodes of heavy snoring that begin soon after falling asleep. The snoring proceeds at a regular pace for a period of time, often becoming louder, but is then interrupted by a long silent period without any breathing [apnoea]. The apnoea is then interrupted by a loud snort and gasp, and the snoring returns to its regular pace. During the apnoeic stage, the sufferer is unable to inhale oxygen or exhale carbon dioxide, resulting in decreased levels of O2 in the blood. This triggers transient arousal to a lighter sleep or wakefulness.

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EXXON VALDEZ OIL SPILL, 1989

“LONG WORKING HOURS, COUPLED WITH A DISTURBED SLEEP PATTERN, CONTRIBUTED TO A DECISION-MAKING ERROR” A few of these arousals do not matter, but severe sufferers experience these arousals several times a minute, hundreds of times a night. Usually, they are completely unaware of their problem unless alerted to it by their partner, but in many cases the partner is so disturbed that they will sleep elsewhere. In severe cases, which are not uncommon, people with OSA can experience severe daytime sleepiness. This occurs during activities such as reading, watching television, or driving on motorways. However, when the sleepiness becomes worse, it begins to interfere with most activities, and the person can fall asleep while talking or even eating.

Central and Mixed Sleep Apnoea Central sleep apnoea is rare. It is defined as a neurological condition causing cessation of all respiratory effort during sleep, usually with reductions in blood oxygen saturation. The airway remains open, but the nerve signals controlling the muscles are not regulated by the brain, resulting in fluctuations in the levels of carbon dioxide in the blood. The lower CO2 can result in breathing becoming very slow or stopping altogether. The individual is then aroused from sleep by an automatic breathing reflex. Mixed apnoea is a combination of OSA and central apnoea. An episode usually starts with a central

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component and then becomes obstructive in nature.

Who is Affected? Increasing age can make the condition more likely. Most affected are those who are overweight and have short, thick necks. Those with structural narrowing of the upper airways or a receding jaw may be more prone. Initial signs include headaches in the morning, poor physical and intellectual performance and agitation.

Diagnosis Diagnosis can be difficult. Anyone suspected of OSA should be referred to a respiratory physician for a sleep study where detailed overnight recordings are made of abnormal breathing, the brains electrical activity, eye movement, muscle activity, heart rate, air flow, respiratory effort, and oxygen in the blood. The patient’s medical history is vital and considers their waking and sleeping habits. A clinical assessment looks at the patient’s weight, body mass index and neck circumference. A detailed examination of the facial structure will look at any abnormalities that can affect their breathing. If overnight in a sleep lab is not feasible, a subjective measure is the Epworth Sleepiness Scale

(ESS) where the patient is asked to score the likelihood of falling asleep in eight different situations with different levels of stimulation. This may be a guide to assess the severity of the sleepiness and would ideally be backed up by an overnight continuous recording of oxygen saturation (SpO2) a measure of the amount of oxygen-carrying haemoglobin in the blood relative to the amount of haemoglobin not carrying oxygen.

Treatment Options Treatment is individually planned, considering their medical history and their physical examination. Underlying issues such as a receding lower jaw or nasal polyps may need to be addressed Lifestyle changes such weight loss, stopping smoking, cutting down alcohol and avoiding sedatives can be beneficial. Continuous positive airway pressure (CPAP) is often selected for moderate to severe sleep apnoea. Air is delivered at low pressure to the upper airways by a tube attached to a nasal mask.

This pressure helps avoid the airway from collapsing and causing obstruction. Side effects can be experienced with nostril irritation, rhinitis, claustrophobia and bloating of the abdominal area being the most common. Surgery to tonsils, polyps and the correction of a deviated septum can also help if present. Other treatment options include oral appliances and can be useful to try in those who cannot tolerate CPAP therapy. They are often less effective but work by allowing the lower jawbone or tongue to be brought forward, helping to keep the airway open. They can also help with snoring. Occupational health professionals can play a vital part in helping to educate their workforce about maintaining a healthy lifestyle and looking out for the signs and symptoms of the condition to alert them to seek medical advice.

Further Information British Snoring and Sleep Apnoea Association, www.britishsnoring.co.uk ⬛

OH Medical is a specialist agency that recruits Occupational Health and Wellbeing professionals nationwide. We can provide both temporary and permanent members of staff at all levels of seniority and responsibility from OH Technician, OH Nurse, OH Advisor to OH Physician

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SPINE EMERG CAUDA

EQUINA SYNDROME

OH TODAY Spring 2021

WRITTEN BY JANE JOHNSON

GENCY T

he group of nerves at the very end of the spinal cord are termed the cauda equina. Cauda equina syndrome is a condition that affects these nerves and due to the potential for this condition to result in devastating disability, is described as a ‘spine emergency’ by the British Association of Spinal Surgeons. It is often described as being a ‘rare’ condition because it is estimated to affect fewer than 1 in 2000 patients with severe low back pain, 6-10 people per million of the population. The cauda equina has five main functions involving the lower limbs, bowel and genitourinary system. Compression of the cauda equina affects these functions. The cauda equina provides: • • • • •

Innervation to the lower limbs Innervation to the anal sphincter Innervation to the urinary sphincter Innervation to the skin around the genitals and the bottom Sexual function

In their literature review of cauda equina syndrome, Fraser, Roberts and Murphy (2009) identified that in 45% of cases pressure to the cauda equina came from a disc. However, pressure may be from other sources such as inflammation or a tumor. The cauda equina can be compressed in scenarios such as: • • • • •

Lumbar disc herniation Trauma such as spinal fracture Spinal mass Spinal stenosis Trauma such as surgery

Gardner, Gardner and Morley (2011) state that it is not clear to what extent the duration and severity of compression of the cauda equina affects the outcome for the person, but that the longer the compression continues, the more likely is the long-term neurological damage. Incorrect or delayed diagnosis of the condition can also result in medicolegal claims.

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Spotting the symptoms of cauda equina The potentially serious consequences of this condition mean that anyone who assesses a person for back pain should be aware of the condition and how it presents. It is especially important because many people delay presenting to a healthcare professional because they do not recognise the significance of the symptoms. In simple terms, people with cauda equina dysfunction may have symptoms affecting the perineal/saddle region, back pain and/or sciatica in one or both legs, altered bladder, bowel and sexual function. For example, a person might notice that they have been unable to empty their bladder for a few days, or alternatively, have had one or more episodes of bladder or bowel incontinence. These symptoms could be vague, subtle, and may not follow a recognisable pattern. Additionally, Greenhalgh et al. (2018) note that certain medications can produce symptoms which are similar to cauda equina syndrome. It is essential for the clinician to take a detailed case history. This involves asking what some people may consider to be embarrassing questions. A cauda equina ‘credit card’ is freely available in multiple languages. Use of this card is essential, for as Greenhalgh describes in the video she and her colleagues made regarding a qualitative study she led, issues regarding communication presented a barrier to early diagnosis: patients often didn’t recognise the subtle symptoms, found it difficult to concentrate on the questions they were being asked due to the severity of pain they were in and did not understand the significance of the questions they were being asked.

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Above: The cauda equina ‘credit card’

CAUDA EQUINA SYMPTOMS • • • • • •

Saddle anaesthesia Severe low back pain Unilateral or bilateral sciatica Bladder dysfunction Bowel dysfunction Sexual dysfunction

DEALING WITH CAUDA EQUINA • Take a detailed history • Explain you are going to ask some very important questions • Explain that some of these questions may be embarrasing but it is important for the person to be honest • Use the cauda equina ‘credit card’ for question prompts • If cauda equina is suspected, advise the person to go to A&E, or phone 111. • Document the history you have taken and the advice you have provided

Greenhalgh and her colleagues can be heard discussing this condition in a podcast created by the Musculoskeletal Association of Chartered Physiotherapists (2019). As clinicians, we can help to identify the symptoms of cauda equina syndrome by asking the person the questions on this card and obtaining clarity regarding the answers. Be matterof-fact with your questioning, don’t skip any questions, and don’t worry about rephrasing questions if you are unclear regarding the answers. Explaining the importance of the questions at the outset will help the patient to understand the rationale behind these. Remember to establish a time frame for the onset of symptoms: ask about the onset of loss of bladder or bowel function; loss of genital sensation and function. For example, ‘how long have you been unable to feel your genital area? 1 hour? 1 day? 2 weeks? 5 years?’ Some tips for actions we can all take as clinicians are provided on the left.

Conclusion

SIMILAR SYMPTOMS FROM MEDICATION Medication

Possible Cauda Equina Symptoms

Tramadol, codeine

Constipation, reduced gastric motility, reduced bladder sensation

Gabapentine, pregabalin

Urinary incontinence

Amitryptaline, nortryptyline

Retention, sexual dysfunction, reduced awareness of need to pass urine

Naproxen, ibuprofen

Retention twice as likely in men as in women

Cauda equina syndrome can result in permanent disability and a delay in diagnosis may give rise to litigation. It is essential that we help a person to identify the symptoms of cauda equina syndrome where these are present, we provide clear advice with regards to what that person needs to do to seek treatment, and we document our process. Cauda equina syndrome is a good example of where being candid and clear with our communication should be the order of the day. In the case of this condition, acting on the day could make a significant difference to the outcome for that person, and people are at the heart of what we do. Jane Johnson is a Clinical Lead Physiotherapist at PAM Group. ⬛

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THE USE OF ASSESSMENT TOOLS IN OCCUPATIONAL HEALTH

Written by Janet O’Neill

he role of OH in sickness absence is well known, because as a profession we understand that being at work is better for health and wellbeing than being out of work. Therefore, our aim is to support employees in remaining at work or returning to work earlier. With sickness absence rising in 2019, 2020 and very likely 2021 due to the current pandemic, more so than ever will OH be relied upon to assist with sickness absence. An employer commonly refers an individual to OH when an individual is struggling in work, there is a risk of them falling out of work or when the individual has already had sickness absence, whether long term, potentially long term, or significant episodes of absence. The referral contains a number of questions posed to the clinician in relation to the health of the individual so that the manager/employer can obtain information to aid their management of that individual. It is well known that the line manager is the most significant person in the individuals working life and has the most influence (NICE) and therefore they need the guidance OH can provide them. However, our added value is the clinical support we can also provide to the employee, therefore reflecting well on the employer.

During the appointment with OH, the clinician needs to assess the individual clinically, using the biopsychosocial model, so as to obtain information on their health matched to work. Taking the information gained, the OH clinician then uses critical thinking skills to make decisions so as to provide justified and evidence-based advice to the employer, answering the questions they have posed. A quality outcome report is essential for a productive partnership between the employer and OH and this requires justification taken from the assessment. Using motivational interviewing skills, they support work as an outcome goal for the individual whilst providing professional and credible clinical advice. This would not be possible without an effective assessment of the individual’s functional capability matched to work, a type of assessment unique to OH. Assessing functional capability requires an objective but empathetic assessment which is evidence-based. This evidence, not only comes from research but from the use of evidence-based tools, of which there are many. The use of health assessment tools allows for information to be collected systematically and facilitates proficiency in critical thinking, recognising patterns, and evaluating function. This is

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particularly important when the assessment involves safety-critical elements of work; risks of work on health and health on work, conflict in the workplace; domestic concerns, and potential impact on an employees’ workability including finances. Assessment tools have been developed from research and are universally accepted as systematic measures of a particular concern. The use of targeted tools provides confidence that the OH assessment is robust and evidence-based, which is important for all stakeholders but specifically supports the professional and expert opinion of the OH clinician. A sickness or presenteeism-based referral could be for any health condition which is why OH is so focused on the functional capability of the individual. There are many evidenced tools that support an assessment and it is up to the clinician to target which tool they feel would help them in their decision-making process. Tools should not be used as a sole factor in an assessment, as the skill of an OH clinician is to marry the outcome of these with their observations, the health history, and questions on current functioning so as to build a picture from which conclusion is drawn. This is of course based on the clinician’s knowledge of the workplace and what adjustments could support that individual if any, based on the risks. In some cases, the tools are easy to choose because they relate specifically to the reason for the referral but in others, the tool can be relevant to a variety of conditions and is adjusted to the functional detriment noted by the individual.

Examples of Tools Should an individual have respiratory issues impacting their capability then the MRC dyspnoea scale is useful to ascertain the impact on their current function with a score of 3 or more indicating some significant impact. However, there can be

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more than one use of a tool as the MRC scale is also useful to understand the risk of severe illness should an individual get coronavirus. A common tool used to assess anxiety and depression is the PHQ (Patient Health Questionnaire) 9 and GAD (Generalised Anxiety Scale) 7. Valuable when used together as often anxiety and depression go hand in hand. Both provide an understanding of the impact on cognitive functioning with sleep, appetite, concentration, motivation, and confidence being of particular importance. Of great significance is question 9 of the PHQ as this allows the question around suicide ideation to be asked, although clinicians need a robust process on how to deal with the outcome should the resulting answer be positive. NICE in their guidance on sickness absence advise that mental health should be assessed with any absence that is longer than 4 weeks. This is because of the impact worklessness and health conditions can have on an individual’s mental health. The PHQ4 is a shortened version of the PHQ9 and GAD7 and is quick and easy to use in this regard. This enables the clinician to ascertain the biopsychosocial elements of an individual’s impact on work. Often a physical condition can have a psychological impact and therefore adversely impact the ability to cope effectively. The EQ5DL is a commonly used outcome measure tool used by physiotherapists, but for OH it can equally be useful in understanding the impact of a condition on an individual’s day-to-day activity and helpfully includes a question on mood; which often co-exists with disability. This then helps not only to understand functional capability but whether any psychological impact is impairing ability and what support can be put in place to improve this for a better work outcome. The AUDIT or CAGE tools are really

The use of targeted tools provides confidence that the OH assessment is robust and evidence-based, which is important for all stakeholders but specifically supports the professional and expert opinion of the OH clinician. helpful when assessing alcohol use. Useful even those who declare no issues where clearly there are concerns, either observed or within the history, as it gives a clear indication of insight. These are important not only when alcohol use impacts health but also for safety-critical roles. PTSD is a real concern today, especially in those roles where exposure to trauma is common like emergency services, but also in frontline workers working with COVID and those who may have been treated within ICU. The PCL-L PTSD Civilian assessment tool is easy to use and can support an understanding of an individual’s behaviour and reactions but also drive treatment needs either via the employer or in directing the GP. The fatigue assessment scale can be used for shift work; burnout; Chronic Fatigue; Fibromyalgia, Lupus, and any condition that can cause fatigue, including arthritis conditions, to understand the impact on cognition and enable signposting appropriately; but also helps with assessing ability to undertake shift and safety-critical work. STOP-BANG for sleep apnoea; important for LGV drivers and other safety-critical roles. This replaces the Epworth sleepiness scale although this latter scale is still used in the Rail industry The standardised mini cognitive assessment tool is commonly used in primary care to screen for memory concerns in older adults. There are times when individuals are referred into OH as memory concerns have become apparent and therefore having a tool to use in

these cases is useful in enabling a direction to be provided to the individual and the organisation. Other tools are the 6 item cognitive impairment scale or the Montreal cognitive assessment scale although this latter requires some training in use. These are a few of the available tools; there are many more with some being condition-specific. MDcalc is an American site with a large number of electronic tools available, all with the evidence base and outcome results that are easy to understand and use. Patient UK also has medical calculators which are electronic and easy to use. Clinicians need to provide the evidence of tools used in their clinical notes; not just the outcome result but all elements of the tool used as this is the evidence that they are basing their opinion on. Other clinicians and perhaps even a tribunal must understand the reasoning behind all decision-making. ⬛

Further Information https://www.xperthr.co.uk/hrbenchmarking/survey/1008/absencerates-and-costs-2020.aspx https://www.personneltoday.com/hr/ guidance-on-occupational-health-casereport-writing/ https://workingwellsolutions.com/amanagement-referral-to-oh/ https://www.personneltoday.com/hr/ good-practice-making-occupationalhealth-referrals/ Melody Rasmor and Carol Brown, Health Assessment for the Occupational and Environmental Health Nurse, JULY 2001, VOL. 49, NO.7, AAOHN https://www.personneltoday.com/hr/ telephone-health-assessments-goodpractice-occupational-health/ https://www.cipd.co.uk/knowledge/ culture/well-being/occupational-healthfactsheet https://www.nice.org.uk/guidance/qs147/ chapter/quality-statement-2-role-ofline-managers https://www.nice.org.uk/guidance/ng146

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GETTING RECOGNISED: SEQOHS ACCREDITATION Why should an Occupational Health provider choose to become a SEQOHS accredited service? Written by Victoria Tait

EQOHS accreditation is a recognised badge of quality in occupational health service. It provides an independent, impartial recognition and an external validation that the service provider has objectively demonstrated their competence and met the required standards. It develops costeffective management guidelines and standardised care and identifies good practice so that it may be furthered and built upon and identifies sub-optimal practice so that it may be improved. It provides a robust governance framework built on best practice and a standard for all OH services to work towards to improve consistency across occupational health services for workers. The process towards accreditation, like ISO 9001, encourages a company to build a quality management system, to risk assess and gather workload data systematically to inform optimal use of resources. It establishes evidence-based local referral guidelines and indications for referral and informs efforts by workers to get the local services workers require. Five years ago most large contracts and principal contractors insisted that Occupational Health providers were SEQOHS accredited if working in the construction industry. The SEQOHS standards were crucial for good researchand evidence-based practices, without it the worker is less protected. However, come 2021, we are seeing this trend changing. There are currently, as of Feb 2021, 183 accredited services and 135 working towards accreditation compared to back in April 2017, 212 services

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working towards accreditation and 242 services accredited. The numbers show over a 30% drop in interest. Most services in the “system” are NHS foundation trusts, Councils and Private Sector OH providers. There are a few inhouse service providers but generally inhouse occupational health services struggle to justify the expense to their senior management team. They do not sell to anyone else so why should they pay for SEQOHS accreditation to set their own comparable standards and audit compliance when there is often a service specific framework they may also need to adopt, such as Oscar Kilo, the National Police Wellbeing Service framework launched in 2017 used by policing forces and organisations and Fire and Rescue Services across the whole of the UK to audit and benchmark themselves as an organisation. That said, inhouse OH services within Transport for London, University of Glasgow and Walkers Snack Foods Ltd, for example, have seen the benefits to being SEQOHS accredited along with some Police and Fires Services where their senior management are very pro SEQOHS. The teams have found it an excellent experience to document their processes (whether that be as a formal document or as a process flow chart) or identify gaps in their processes and existing services so that they may be remedied as well as identifying the staff and other resources required to deliver an effective consistent service. It has been beneficial in ensuring clinical governance, competency, for driving audit, and identifying areas for clinical

training and professional development of their staff. It has also been worth it in terms of proving to senior management that they are doing things to the highest standards and the most appropriate standards for occupational health and demonstrating the value that their department brings to a company. Even as an in-house service they have found that they need to know that they are still competitive in terms of cost, time, delivery, quality of service to their own business.

membership fee gives you access to one place on a mandatory stage B training day (per 5 years), the self-assessment tool, the action planning tool, the knowledge management system, all on the online SEQOHS web tool.

It is, however, an expensive process for any small company that employs someone else. For a single-handed provider (any OH physician or practitioner who operates independently as a peripatetic service or services with offices, with access to an identified occupational physician listed on the GMC specialist register, including for advice or the escalation of cases and have administrative support) the fees start at £250 but as soon as you employ directly or contract any other clinical or technical staff you become a SEQOHS “small service”.

*figures quoted exclusive of value added tax.

For a small service, the stage 1 annual fee is £1200 unless you have more than seven sites or are providing OH services to 145,000 or more workers, in which case a service would be considered a ‘large service’ and the stage 1 annual fee would be increased to £2000.

Stage two begins once a service signs off its self-assessment and is ready to be formally assessed by an assessment team. Once you progress to stage 2 the annual fee is £2400 for a small service or £3300 for a large service.

Occupational health providers involved in sample collection and end to end testing of COVID-19 are also now being asked by the Department of Health and Social Care to UKAS accredit against ISO 15189:2012 (and ISO 22870:2016 for point of care testing) or ISO 17025:2017 with a starting cost of £1500+VAT. Another additional cost to externally prove the quality of your service, leaving many Occupational Health providers asking what can be done to re-cost, re-energise or change the SEQOHS accreditation process so more OH services believe it is a worthwhile investment for themselves and ultimately for the wellbeing of the workers which they assess.

In-house occupational health services struggle to justify the expense to their senior management team

Victoria is a consultant who supports organisations, small and large through accreditations. ⬛

The service’s stage one annual

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INTERVIEW

JANET O’NEILL iOH DIRECTOR OF PROFESSIONAL DEVELOPMENT

INTERVIEWED BY LYNN PRATT

I had the pleasure of catching up with Janet O’Neil, iOH Director of Professional Development to find out more about how she got into OH and her thoughts about the future. How did you get into OH? I was working as a canteen manager in a factory in Swaziland when they heard I was a registered nurse. They asked me to set up an OH clinic for the factory which I did (scary business as it was so out of my comfort zone) and for a time I ran the kitchen in the morning and the OH clinic in the afternoon. They paid for me to do my health and safety qualification and my first Occupational health qualification. In the UK I went on to do the OH Diploma at Warwick and the MSc in Workplace health at Nottingham University. What are you currently doing? My current role is as Clinical Nurse Director with People Asset Management or PAM OH solutions which mainly covers Clinical Governance and Training although I have fingers in a lot of areas which makes it very interesting. This helps with my role in iOH as Director for CPD as I am always looking for relevant and appropriate training to support individuals to grow in their Occupational Health practice.

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You wear several OH “hats”. How do you relax? Ice Skating is an amazing hobby because not only can you lose yourself completely but you always have something to work on. Up until the pandemic; I often competed in adult competitions and this forced me to totally forget work and focus entirely on preparing. But during the pandemic, I have discovered online exercise classes which are easy to join and enable you to go from being a professional to a bouncing, sweaty fanatic within a few seconds. I also love walking but just don’t do enough of it at the moment. Who and what has inspired/guided you most? When I started in OH in the UK; I was employed by Dawn Knight and Dr. Bob Guest. They were not only inspirational but great teachers. My love of Occupational Health was reinforced by Jane Fairburn; founder of PAM. Her focus on practical and pragmatic employer advice has stayed firmly with me and I

Ice skating in Lake Pla

acid, USA

still work in her way. She taught me so much. Where do you get support from? I am very fortunate to work with an excellent OHP but also work within a multidisciplinary team. OH has a broad remit and the tasks we undertake are wide-ranging so getting support from specialists is such an added value to my growth and development. I also find the support from the wider community invaluable. OH needs to be aware of so many elements within the workplace; organisational psychology, employment law, health and safety, public health, and many more. Being part of organisations like iOH, SOM, etc., and keeping up to date via social medial is invaluable in providing support. We are so fortunate to have access to so many free webinars (including iOH 21 for 21), podcasts, elearning modules from every different sector that support our growth and development. Do you have any advice for those considering going into OH or considering further academic study? If anyone is considering moving into OH, I just say “go for it”. There is nothing quite like OH for developing autonomy and for enabling that very particular advisory skill for people and organisations. It is a really special profession. I am not a good person to ask about the NMC part 3 or specialist practitioner qualification. I am not SCPHN myself and I have seen many people who have this title who are in no way competent. I believe competency comes from experience and self-learning and this comes from whichever university course suits you and your experience. However, I do believe in getting a qualification in Occupational Health, so as to validate ourselves. The most important part of any course is the content. Have a look at the content and ask yourself how relevant it is to your

practice. Speak to a number of OH professionals to see what is important to them, looking for common themes. Personally, I believe health surveillance and assessment is core alongside absence management. What are the challenges you see OH facing in the next few years? OH needs to expand, develop and change. Our core goals are still important but if we don’t move with the needs of the workforce and employers; we will get lost. Many organisations add good value in the health and wellbeing market and if we don’t start thinking outside the box, we will be eclipsed. Keeping an eye on the latest research and marrying it to the services we deliver is also a challenge as the research is evolving so quickly. I think what I am saying is that OH needs to be agile and flexible to keep up to date with what the market needs. How do you see the future of OH? The future of OH is strong. We have the ability to demonstrate our value to the employer and therefore the topics. I think all OH professionals need to consider is the economy, the impact of this on organisations; what direction organisations are moving into – what is important to them, and digital health. Technology is moving at a fast pace due to the pandemic and therefore we absolutely need to keep up to speed and understand how this can improve the service we deliver as well as the speed we deliver it within. Exciting times ahead. What’s next for you Janet? I recently started as a peer reviewer, so I am enjoying learning this skill. I am also involved in compiling the CPD section of the iOH website which I am really enjoying. It would be great to get more iOH members involved. If you would like to help, please reach out to me at board@ioh.org.uk. It would be great to work together with more of you. ⬛

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PROFESSIONAL DIPLOMA IN TRAVEL HEALTH — COURSE REVIEW

s we come out of the pandemic, Occupational Health departments around the country will be preparing for an influx of travellers who will require travel health advice and immunisations. With many OH practitioners working at home over the last year, skills may have become a little rusty! Last May I took the plunge back to learning and started the Professional Diploma in Travel Health (DipTH) at Liverpool School of Tropical Medicine (LSTM). I have just completed the course. As an OH practitioner working for a global oil company, I was equipped with essential knowledge, skills, and competencies in travel health. The course is jointly developed by LSTM in conjunction with the National Travel Health Network and Centre (NaTHNaC) and is delivered by experienced clinical professionals from the two organisations. The programme provides a platform for confident practice through interactive online learning, an opportunity for reflection, and continuing professional development with specialists and peers. Divided into four modules there is also the opportunity to undertake the following as standalone modules too.

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• • • •

Travel Vaccination Principles and Practice Governance and Safety in Travel Health Malaria Prevention in Travel Health Hazards in Travel Health

Written by Lynn Pratt Vice President, iOH

Each module has a 1500-word summative assessment followed by a final written assessment and an MCQ exam. Most students complete the diploma in 6-15 months. I had the opportunity to study with qualified health professionals such as general nurses, occupational health advisers, doctors, pharmacists, and travel and expedition health professionals from around the globe. In summary, I would strongly recommend this course if you wish to develop your theoretical and practical knowledge in travel health. The variety of interactive online educational tools, additional online tutorials and regular feedback from the tutors really kept me focused. At just £2595, the course offered excellent value with the added benefit of being able to study from home. For further information: https:// www.lstmed.ac.uk/study/courses/ professional-diploma-in-travel-healthonline. ⬛

I would strongly recommend this course if you wish to develop your theoretical and practical knowledge in travel health.

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CHANGING LIVES Make a difference with a profession that enhances and enriches people’s lives Gain a professional qualification in occupational health nursing Build your understanding of clinical practice, wider public health and leadership and management Develop specialist assessment, leadership and management skills Develop and build on your existing knowledge to ensure that you meet the competencies set by the Nursing and Midwifery Council (NMC), and you’re eligible to gain a registrable qualification Become part of the public health workforce working towards improving people’s lives and their health outcomes. This course is for NMC registered nurses who want to gain a professional qualification in occupational health nursing. If you have either a Diploma or Advanced Diploma in nursing studies this course can be studied at degree level to top up your qualification. We also offer a Postgraduate Diploma, leading to a full MSc in this discipline for those that already hold a degree. Find out more about studying Occupational Health at Derby and why we’d love to welcome you Find out more about our undergraduate and postgraduate courses