Sustainability, Resilience and Occupational Health

Question 1

What are the Horsfal recommendations to the GMC (2014)?

Answer 1

It is extremely important that medical students have not only the clinical skills and knowledge to move from medical school to the Foundation Programme but also have the resilience and coping techniques to help them face difficult circumstances as their careers progress.
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 2

What is the GMC guidance on supporting students with mental health conditions?

Answer 2

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.

Question 3

What are some of the ways that the medical school can promote well being?

Answer 3

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
providing opportunities for physical exercise and yoga, which some people find useful to help them manage their stress levels

Question 4

What is the Oxford Dictionary definition of resilience?

Answer 4

‘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.

Question 6

What does resilience encompass?

Answer 6

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

Question 7

The following was taken from a summary about elite athletes. Similarities to medical students?

Answer 7

High internal and external expectations
Win at all costs attitude
Parental pressures
Long practices
Excessive time demands
Perfectionism
Potential for inconsistent coaching
Cycle of above can cause stress

Question 8

What are the personal strengths underpinning resilience?

Answer 8

High frustration tolerance
Self acceptance
Self belief
Humour
Perspective
Curiosity
Adaptability
Meaning

Question 9

What behaviors are there to support resilience?

Answer 9

Building / having support networks – positive relationships
Reflective ability
Assertiveness
Avoiding procrastination
Developing goals – realistic plans and ability / motivation to follow them through
Time management
Work – life balance

Question 10

What are the sources of burnout?

Answer 10

Personal
- Perfectionism
- Denial
- Avoidance
- Micromanaging
- Unwilling to seek help
- Being too conscientious
Professional
- Culture of invulnerability
- Culture of presenteeism
- Blame culture / silence
Systemic
- Overwork
- Shiftwork
- Lack of oversight
- Chaotic work environments
- Lack of teamwork
- Fractured training

Question 11

How might stress or burnout present in medical students?

Answer 11

The struggling student:

• Repeatedly failing or nearly failing
• Handing in work late
• Poor attendance
• Absence due to illness
• Behavioural issues
• Fitness to practice issues
• Lack of engagement with the course
• Poor communication with staff, peers and patients

Question 12

What is the role of resilience in practice?

Answer 12

Initial reactions
- Doubt, anger, fear, worry, misunderstood, unappreciated, sorrow, regret.
Resilience may…
Lead to reflection
- Did I make the right decision, could I have done things differently?
- Discuss with peers - SEA
Lead to improvement
- Do I need to learn anything to prevent the same happening again?
Lead to returning wiser and better
- How will I communicate better? Will I change my practice in the future?

Question 13

What factors will help build resilience?

Answer 13

Factors aiding resilience:
Intellectual interest
- Job satisfaction, career progression, variability (if wanted), capacity to develop special interest
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
Time management and work life balance
- Ensuring time for hobbies, leisure, relaxation, self expression
Continuing professional development
Support including team working
- Supportive relationships within and out-with medicine
Mentors
- Help trainees adapt to change and react to stress

Question 14

It is not all about personal change / resilience, what other factors would help build resilience?

Answer 14

Professional attitudes
- Changing sense of perfectionism, presenteeism, culture of silence
- Better support for those struggling or after difficult events
Societal attitudes
- Changing culture of blame, reduce perceived threat of complaints
- Public acceptance of mistakes? Patients’ personal responsibility for health?
Structural changes
- Improved shift patterns, better work – life balance, less fractured training, regular breaks, a cup of tea

Question 15

What is the Conceptual Model of Medical Student Well-being: Promoting Resilience and Preventing Burnout?

Answer 15

See diagram.

Referenced in earlier paper (‘Doctors need to be supported not trained in resilience’) as the Unified Model
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

Question 16

What is an occupational history?

Answer 16

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.

Question 17

When is a shortened occupational history possible?

Answer 17

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

Question 18

What is included in an occupational history?

Answer 18

A description of the present and previous jobs from leaving school.
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?
Did the symptoms improve when not exposed / not at work e.g. at weekends, holidays?
Determine the duration and intensity of exposure e.g. was it so noisy it was impossible to communicate
Is personal protection used e.g. what kind of mask? Or equally is an appropriate chair / desk provided?
What maintenance is in place for the protection measures?
Do others suffer similar symptoms?
Are there known environmental hazards in use?
Any hobbies, pets, worked overseas, moonlighting?

Question 19

What is the fit note?

Answer 19

This replaced the ‘sick note’ in April 2010.
It’s purpose is to facilitate earlier discussion about returning to work and about rehabilitation.
It now includes items of consideration for employers when signing a patient’s return to work.
It can only be completed by a Doctor
It is advice to patients as employees, is not binding on the employer and does not affect Statutory Sick Pay
It is required if the patient has been off more than 7 consecutive days ( including non working days)

Question 20

What is the fit note form?

Answer 20

See diagram.

Question 21

What is the role of the occupational health service?

Answer 21

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.

Occupational health specialists are ideally and uniquely placed to support and help people stay in work and live full and healthy lives.
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.
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.

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

Modern occupational health requires a multidisciplinary approach where doctors work alongside a range of associated healthcare professionals including nurses, ergonomists, hygienists, occupational health advisors, physiotherapists, psychiatrists, psychologists and therapists

Question 22

What are the four fit note options?

Answer 22

Phased return to work
- Start with reduced hours each day and build up – help build capacity again and allow time for rehab
Altered hours
- Work at different times of day e.g. are early mornings hardest?
Amended duties
- Change in work practice or content e.g. less time sitting or breaking up the day differently to allow more movement – shorter surgeries, built in breaks etc
Workplace adaptation
- e.g. changes to seating to support back better.

Question 23

Is a fit note legally binding?

Answer 23

These are not legally binding on an employer, they are suggestions to facilitate a return to work. If OH involved, they could require an organisation to make any changes reasonable for the size of organisation.

Question 24

What is the effect of unemployment on health?

Answer 24

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:

• Higher mortality;
• Poorer general health, long-standing illness, limiting longstanding illness;
• Poorer mental health, psychological distress, minor psychological/psychiatric morbidity;
• Higher medical consultation, medication consumption and hospital admission rates.

Question 25

What does re-employment lead to?

Answer 25

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

What is sustainability?

Answer 26

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

Question 27

How can sustainability in the NHS be looked at?

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”
In Scotland we have a National Policy Document “Realistic Medicine” that in part relates to this.

Question 28

How can the NHS provide low carbon clinical care, maintaining NHS sustainability?

Answer 28

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

Question 29

What makes the case for a sustainable NHS in England?

Answer 29

NHS Sustainability Development Unit’s Strategy Document (NHS England)

Question 30

What has the SDU shown?

Answer 30

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

Question 31

What has the NHS carbon reduction strategy committed to?

Answer 31

The NHS carbon reduction strategy, 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.
So the health sector will be forced to reduce its carbon emissions.

Question 32

What was the greatest part of carbon emission?

Therefore, what is sustainability about?

Answer 32

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 33

What would low Carbon Clinical Care look like?

In practice?

Answer 33

It will – 
Be better at preventing conditions
Give greater responsibility to patients in managing their health.
Be leaner in service design and delivery
Use the lowest carbon technologies

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 change.
- 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.
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.
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
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 34

What about a focus on transport?

Answer 34

Transport accounts for almost 25% of all fossil fuel greenhouse gas emissions
Cutting emissions through walking and cycling and less vehicle use brings large health benefits e.g. reduction in diabetes, CV disease and depressio

Question 35

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

Answer 35

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
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
Institutional plans
- e.g. 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 36

What is the sustainability of the workforce?

Answer 36

“Figures show extent of NHS reliance on foreign nationals”
How much of the NHS workforce has potentially migrated to the UK?
- 11% of all staff and 26% of doctors are non-British
Where do they tend to come from?
- India, the Philippines, Ireland, Poland, Nigeria, Zimbabwe, Portugal, Pakistan, Spain and Germany.
What are the potential risks to the UK and also to their country of origin?
What changes in the UK or their country of origin might change this?
Is this sustainable long term?

Question 37

How is the NHS “continuing over time”?

Answer 37

In Scotland the SNP 2015 manifesto committed to
“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 necessitate 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 38

What are the contrasting approaches with regards to the NHS?

Answer 38

There is an increasingly elderly and comorbid population, which continues to place greater strains on the NHS.
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.
There are therefore different approaches currently between Scotland and England in terms of the ongoing nature and provision of NHS services in the context of rising need for NHS services

Question 39

What is The New GP Contract 2018?

Answer 39

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 40

How should the definition of health change?

Answer 40

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’