Sustainability, Resilience and Occupational Health

Question 1

Mild-to-moderate mental health conditions are common and can affect what percentage of the population, what may they include?

Answer 1

Mild-to-moderate mental health conditions are common and can affect 15–25% of the general population at any one time.

They include:

• Depression
• Generalised anxiety disorder
• Panic disorder
• Social anxiety disorder
• Obsessive compulsive disorder
• Post-traumatic stress disorder.

However, medical students have a higher prevalence of depression and anxiety than the general population

Question 2

Recommendations to the GMC (Horsfall, S – 2014) ?

Answer 2

The GMC continue to work with medical schools to ensure that emotional resilience training is a regular and integral part of the medical curriculum

Both medical students and doctors in training have specific training modules in their curriculum that explain the implications should they be subject to a serious complaint and investigation

The GMC continue to work with medical students and doctors in training to promote its regulatory requirements

The GMC continue to work with all medical schools to ensure its standpoint on recreational drug use and alcohol is better communicated to students

Question 3

GMC guidance – supporting students with mental health conditions?

Answer 3

Promoting well-being
- As well as supporting students who have mental health conditions, medical schools should also promote well-being among all of their students.

Some of the ways that medical schools can do this include:

• Delivering group learning exercises focusing on how to deal with stress
• Providing and promoting online resources on keeping healthy, including advice on healthy lifestyles
• Providing sessions on techniques such as mindfulness and meditation, and providing opportunities for physical exercise and yoga, which some people find useful to help them manage their stress levels.

Question 4

Resilience – Definition?

Answer 4

The Oxford Dictionary -
‘Resilience’ ( a term imported from the language of physics) as:
The capacity to recover quickly from difficulties; toughness, or
the ability of a substance or object to spring back into shape; elasticity.

This term is also used in other disciplines such as physiology and psychology to refer to a person’s ability to resist adversity without resulting in physical or psychological disability.

Question 5

What is resilience?

Answer 5

Resilience is an emotional competence or a personality characteristic that deals with negative effects of stress and promotes adaptation.

Resilience can also, however, be an acquired virtue or behaviour and requires continuous improvement.

Resilience encompasses several dimensions including self-efficiency; self-control; self-regulation; planning and perseverance.

The medical profession, as many other professions, can be very stressful and we need to maintain emotional wellbeing and resilience.

Question 6

What may lead to increased stress in athletes, medical students or other highly competitive jobs?

Answer 6

1) High internal and external expectations
2) Win at all costs attitude
3) Parental pressures
4) Long practices
5) Excessive time demands
6) Perfectionism
7) Potential for inconsistent coaching

Question 7

The personal strengths underpinning resilience?

Answer 7

1) High frustration tolerance
2) Self acceptance
3) Self belief
4) Humour
5) Perspective
6) Curiosity
7) Adaptability
8) Meaning

Question 8

Behaviours supporting resilience?

Answer 8

1) Building / having support networks – positive relationships
2) Reflective ability
3) Assertiveness
4) Avoiding procrastination
5) Developing goals – realistic plans and ability / motivation to follow them through
6) Time management
7) Work – life balance

Question 9

Sources of burnout?

Answer 9

1) Personal
- Perfectionism, denial, avoidance, micromanaging, unwilling to seek help
- Being too conscientious

2) Professional
- Culture of invulnerability
- Culture of presenteeism
- Blame culture / silence

3) Systemic
- Overwork, shiftwork, lack of oversight
- Chaotic work environments
- Lack of teamwork, fractured training

Question 10

How might stress or burnout present in medical students?

Answer 10

1) Repeatedly failing or nearly failing
2) Handing in work late
3) Poor attendance
4) Absence due to illness
5) Behavioural issues
6) Fitness to practice issues
7) Lack of engagement with the course
8) Poor communication with staff, peers and patients

Question 11

Resilience in practice?

How would you feel initially?
How would you react?
How might your reaction show your resilience or lack of it?
What does it mean to be resilient in this situation?

Answer 11

Initial reactions
Doubt, anger, fear, worry, misunderstood, unappreciated, sorrow, regret.

Resilience may…

1) Lead to reflection
- Did I make the right decision, could I have done things differently?
- Discuss with peers - SEA

2) Lead to improvement - Do I need to learn anything to prevent the same happening again?
3) Lead to returning wiser and better - How will I communicate better? Will I change my practice in the future?

Question 12

Factors aiding resilience - Personal?

Answer 12

1) Intellectual interest - Job satisfaction, career progression, variability (if wanted), capacity to develop special interest
2) Self awareness and self reflection - Recognise and accept personal limits, establish boundaries in doctor-patient relationship, less self critical. Aided by mindfulness based stress reduction
3) Time management and work life balance - Ensuring time for hobbies, leisure, relaxation, self expression
4) Continuing professional development
5) Support including team working - Supportive relationships within and out-with medicine
6) Mentors - Help trainees adapt to change and react to stress

Question 13

Factors aiding resilience - Professional?

Answer 13

1) Changing sense of perfectionism, presenteeism, culture of silence
2) Better support for those struggling or after difficult events

Question 14

Factors aiding resilience - Societal?

Answer 14

1) Changing culture of blame, reduce perceived threat of complaints
2) Public acceptance of mistakes? Patients’ personal responsibility for health?

Question 15

Factors aiding resilience - Structural?

Answer 15

Improved shift patterns, better work – life balance, less fractured training, regular breaks, a cup of tea

Question 16

Factors aiding resilience?

Answer 16

1) Personal
2) Professional
3) Societal
4) Structural

Question 17

Copiing reserve model Slide 41 learn to draw

Answer 17

A coping reserve that can be filled or emptied

Personality traits, temperament and coping style form the internal structure

Omits importance of organisational and sociocultural issues

Incorporates:

1) Negative input
- Stress
- Internal conflict
- Time and energy demands

2) Positive input:
- Psychosocial support
- Social/healthy activities
- Mentorship
- Intellectual stimulation

3) Outcomes:
- Burnout
- Resilience

Question 18

Help services at aberdeen for students?

Answer 18

1) Counselling service

2) Student Welfare Officer

Question 19

What is an occupational history?

Answer 19

An occupational and environmental history is a chronological list of all the patient’s employment with the intention of determining whether work has caused ill health, exacerbated an existing health problem or has ill health had an impact on the patient’s capacity to work.

A shortened history is possible within a GP consultation if the problem is acute and likely related to current work.

Question 20

What information might/should be gather within an occupational history?

Answer 20

1) A description of the present and previous jobs from leaving school.
2) Identifying any exposure to chemicals or other hazards e.g. stress, overwork, adverse working environment, in this situation is the fact that role largely sedentary exacerbating or causing his back pain?
3) Did the symptoms improve when not exposed / not at work e.g. at weekends, holidays?
4) Determine the duration and intensity of exposure e.g. was it so noisy it was impossible to communicate
5) Is personal protection used e.g. what kind of mask? Or equally is an appropriate chair / desk provided?
6) What maintenance is in place for the protection measures?
7) Do others suffer similar symptoms?
8) Are there known environmental hazards in use?
9) Any hobbies, pets, worked overseas, moonlighting?

Question 21

What options are available for GPs when patients present with illness/pain and need time of work?

Answer 21

1) Treat underlying condition e.g. pain = analgesia, advice, information regarding stretching, exercise or referral to physiotherapy
2) Consideration of a fit note

Question 22

Information of the “Fit note”?

Answer 22

1) It’s purpose is to facilitate earlier discussion about returning to work and about rehabilitation.
2) It now includes items of consideration for employers when signing a patient’s return to work. E.g. Phased return, adjusted hours, adaptions to the work place and/or amendments of duties
3) It can only be completed by a Doctor
4) It is advice to patients as employees, is not binding on the employer and does not affect Statutory Sick Pay
5) It is required if the patient has been off more than 7 consecutive days ( including non working days)

Question 23

Role of occupational health?

Answer 23

1) For patients who are off for longer periods of time or with more complex needs, referral to a specialist occupational health service is an option.
2) Occupational health specialists are ideally and uniquely placed to support and help people stay in work and live full and healthy lives.
3) They play a key role in ensuring the health and well being of the working population by preventing work-related ill health and providing specialist rehabilitation advice.
4) They provide independent, impartial advice to employers and employees on the effects of work on health and the effects of health on work.

For example, the opinion of an occupational health specialist might be crucial in determining how to manage a capability issue or in providing key evidence in a claim to an employment tribunal. As well as addressing issues that occur, a lot of the work of an occupational health service is proactive, aiming to reduce potential problems in the workplace.

Question 24

Examples of occupational health role?

Answer 24

1) Help prevent work-related ill health
2) Advise on fitness for work, workplace safety, the prevention of occupational injuries and disease
3) Recommend appropriate adjustments in the workplace to help people stay in work
4) Improve the attendance and performance of the workforce – for example by assisting in the management of sickness absence
5) Provide rehabilitation to help people return to work, and give advice on alternative suitable work for people with health problems
6) Promote health in the workplace and healthy lifestyles
7) Recommend and implement appropriate policies to maintain a safe and healthy workplace
8) Conduct research into work related health issues
9) Ensure compliance with health and safety regulations including minimising and eliminating workplace hazards
10) Advise on medical health and ill-health retirement

Question 25

Effect of unemployment of health?

Answer 25

1) There is a strong association between worklessness and poor health. This may be partly a health selection effect, but it is also to a large extent cause and effect. There is evidence that unemployment is generally harmful to health, including: 2) Higher mortality; 3) Poorer general health, long-standing illness, limiting longstanding illness; 4) Poorer mental health, psychological distress, minor psychological/ psychiatric morbidity; 5) Higher medical consultation, medication consumption and hospital admission rates. 6) There is evidence that re-employment leads to improved self-esteem, improved general and mental health, and reduced psychological distress and minor psychiatric morbidity. The magnitude of this improvement is more or less comparable to the adverse effects of job loss.

Question 26

Definition of sustainability?

Answer 26

The Cambridge Dictionary defines sustainability the ability to be: “Able to continue over a period of time”

Question 27

Sustainability in the NHS?

Answer 27

It could be looked at in relation to low carbon clinical care and the environment. It could be looked at in relation to the ability of the NHS to “Continue over time”

Question 28

Low Carbon Clinical Care and NHS Sustainability?

Answer 28

1) Prioritise Environmental Health 2) Substitute harmful chemicals with safer alternatives. Reduce and safely dispose of waste 3) Use energy efficiently and switch to renewable energy. Reduce water consumption 4) Improve travel strategies 5) Purchase and serve sustainably grown food 6) Safely manage and dispose of pharmaceuticals 7) Adopt greener building design and construction. 8) Purchase safer more sustainable products

Question 29

The SDU has shown that short term reduction of what percentage in emissions is technically feasible without compromising standards of care?

Answer 29

The SDU has shown that short term reduction of 40% in emissions is technically feasible without compromising standards of care.

Question 30

Based on national targets set by the Climate Change Act 2008, commits the health service to more than what percentage reduction in emissions over the next 30 years?

Answer 30

Based on national targets set by the Climate Change Act 2008, commits the health service to more than 80% reduction in emissions over the next 30 years

Question 31

What is the greatest contribution to carbon emission by the NHS currently?

Answer 31

The greatest part of carbon emission from NHS England is from purchasing of goods and services, 22% is from purchase of pharmaceuticals. Sustainability is not just about more efficient use of energy in buildings but also of equipment and consumables.

Question 32

What would low Carbon Clinical Care look like?

Answer 32

1) Be better at preventing conditions 2) Give greater responsibility to patients in managing their health. 3) Be leaner in service design and delivery 4) Use the lowest carbon technologies

Question 33

What would low Carbon Clinical Care look like - Be better at preventing conditions?

Answer 33

It will be better at preventing conditions. On World Health Day 2008, the director of WHO, Margaret Chan, forecast an increase in deaths worldwide from malnutrition, diarrhoea and infectious disease attributable to climate changes. Specialities should aim to tackle underlying causes of disease ; the social, economic and environmental determinants of health. Make effective contraception more widely and easily available worldwide to help reduce the financial, social and environmental effects of unwanted pregnancies. Increasing access to clean water, proper sanitation and education on hygiene techniques such as hand washing.

Question 34

What would low Carbon Clinical Care look like - Give greater responsibility to patients in managing their health?

Answer 34

Give greater responsibility to patients in managing their health. Many patients could be empowered to take on greater role in the management of their health and healthcare. For example the use of information prescriptions instead of medication prescription by an East London GP practice.

Question 35

What would low Carbon Clinical Care look like - Be leaner in service design and delivery?

Answer 35

Be leaner in service design and delivery e.g. combine clinics for diabetes, cardiovascular and stroke, use ‘lean’ principles to eliminate duplication and poorly targeted investigations. Reduce the number of steps in patient pathway of referral to treatment by channelling patients from the clinic direct to pre assessment, reducing their journey time. Greater use of online records, email and telephone can reduce travel emissions by moving information in place of patients, staff and lab samples. More effective prescribing remembering pharmaceuticals comprise a fifth of carbon emissions from NHS England. Disposing of the unused drugs has a marked environmental impact considering some reported figures of almost 50% non compliance

Question 36

What would low Carbon Clinical Care look like - Use the lowest carbon technologies?

Answer 36

Use the lowest carbon technologies. Inclusion of sustainability measures in the evaluation of medical technologies will allow service planners, clinicians and patients to choose clinically effective treatments with the best environmental profile and will encourage further development eg green nephrology project provides a model of sustainability. It has looked at dialysis water recycling, heat exchangers, reduction in packaging and virtual clinics

Question 37

How much does transport contribute to greenhouse gas emissions?

Answer 37

Transport accounts for almost 25% of all fossil fuel greenhouse gas emissions

Question 38

What modifications to health related travel would have an impact on reducing the carbon footprint of health delivery and improve personal health?

Answer 38

1) Reduce the need to travel: - teleconferencing, video conferencing for follow-up appointments where clinical examination not needed. - One stop clinics where consultation, diagnostic testing and management plan all done on the same day in the same facility. - Multiple clinics on the same day – coordinating care between different specialities for the same patient 2) Better ways to travel: car pooling, car sharing, fuel efficient vehicles (hybrid or electric) , health service transport e.g. buses to transport patients to and from clinics and hospital 3) Institutional plans: - Providing facilities for people to cycle to work, utilise bus services. - Incentivise active travel – reduce car parking spaces, cycle to work schemes to provide for the purchase and use of bikes, encourage walking to work or incentivise use of public transport.

Question 39

The NHS “continuing over time” - Scotland?

Answer 39

“Meet the funding challenge” laid down by the chief executive of the English NHS in the Stevens Report by voting for a £24 billion increase in health spending, £9.5 billion more inflation. This will lead to the Scottish NHS budget increasing by £2 billion.” “They will vote to stop the supposed privatisation of the English NHS.” There has been legislation passed in Scotland in 2014, that came in to place on April 1st 2016 relating to the Integration of Health and Social Care. This brought together NHS and local council care services under one partnership arrangement for each area. This will necessitated a closer working relationship between NHS workers such as GPs and Social Care providers such as Care Managers and Social Work. They share funding of around £8 billion of Health and Social Care Funding.

Question 40

The NHS – Contrasting Approaches - England?

Answer 40

There is currently much debate in England in respect of the commissioning of NHS services by any qualified provider, which could be perceived as gradual privatisation of services. In addition on the 21st April 2016, the UK government announced an annual investment in the General Practice sector of the NHS of 2.4bn by 2020-21. This included funding for a £500m sustainability and transformation package that includes £56m for a practice resilience programmes.

Question 41

The New GP Contract 2018?

Answer 41

In 2018, a majority of General Practitioners in Scotland voted for a changed national GP contract. The BMA in Scotland stated it will reduce workload and improve recruitment. Additional members will become part of the practice team and allow GP’s to fulfil their role as expert medical generalists. There are a number of changes in staffing and funding designed to promote sustainability of General Practice. The effect of the changes will be to reduce risk to practices and to promote sustainability.

Question 42

What are the pro’s and con’s of different approaches?

Answer 42

- Ongoing and increased funding of the NHS - Integration of with Social Care and a Shared budget - Provision of NHS services by Private Providers

Question 43

Definitions fo health?

Answer 43

It is now been suggested we should remodel the WHO definition of ‘what is health’ proposed in 1946 from : ‘a complete state of physical, mental and social wellbeing and not merely the absence of disease’ to ‘resilience, adaptation and self management in the face of physical, social and emotional challenges’