Ewan B. Macdonald

The assessment of poorly performing doctors: the development of the assessment programmes for the General Medical Council's Performance Procedures

Modernization of medical regulation has included the introduction of the Professional Performance Procedures by the UK General Medical Council in 1995. The Council now has the power to assess any registered practitioner whose performance may be seriously deficient, thus calling registration (licensure) into question. Problems arising from ill health or conduct are dealt with under separate programmes.

Mercury vapour levels in dental practices and body mercury levels of dentists and controls

Aim A study of 180 dentists in the West of Scotland was conducted to determine their exposure to mercury during the course of their work and the effects on their health and cognitive function.Design Data were obtained from questionnaires distributed to dentists and by visiting their surgeries to take measurements of environmental mercury.Methods Dentists were asked to complete a questionnaire including items on handling of amalgam, symptoms experienced, diet and possible influences on psychomotor function such as levels of stress and alcohol intake. They also completed the 12-item General Health Questionnaire. Dentists were asked to complete a dental chart of their own mouths and to give samples of urine, hair and nails for mercury analysis. The dentists were visited at their surgeries where environmental measurements were made in eight areas of the surgery and they undertook a computerised package of psychomotor tests. One hundred and eighty control subjects underwent a similar procedure, completing a questionnaire, having their amalgam surfaces counted, giving urine, hair and nail samples and undergoing the psychomotor test procedure.Results Dentists were found to have, on average, urinary mercury levels over 4 times that of control subjects although all but one dentist had urinary mercury below the Health and Safety Executive health guidance value of 20 μmol mmol−1 creatinine. Urine was found to be a better biological marker for mercury exposure than hair or nails.Dentists were significantly more likely than control subjects to have suffered from disorders of the kidney but these symptoms were not significantly associated with their level of mercury exposure as measured in urine. One hundred and twenty two (67.8%) of the 180 surgeries visited had environmental mercury measurements in one or more areas above the Occupational Exposure Standard (OES) set by the Health and Safety Executive. In the majority of these surgeries the high levels of mercury were found at the skirting and around the base of the dental chair. In 45 surgeries (25%) the personal dosimetry measurement (ie in the breathing zone of dental staff) was above the OES.Conclusion On the basis of these findings, it is recommended that greater emphasis should be made relating to safe handling of amalgam in the training and continuing professional development of dentists, that further studies are carried out on levels of mercury exposure of dental team members during the course of their working day, and that periodic health surveillance, including urinary mercury monitoring, of dental personnel should be conducted to identify possible effects of practising dentistry.

Mental health as a reason for claiming incapacity benefit - a comparison of national and local trends.

BACKGROUND Getting incapacity benefit (IB) claimants into work has become a focus for policy makers. Strategies to help this group depend on an understanding of the reasons for claiming benefit at a local level where variations from a national strategy may be needed. METHODS Data supplied by the Department for Work and Pensions (DWP) was analysed to establish reasons for claiming benefit in Scotland and Glasgow between 2000 and 2007. RESULTS There has been a continuing rise in mental health diagnosis and a corresponding fall in musculoskeletal diagnosis during this period. More people were claiming because of mental health problems in Glasgow than in Scotland. Also those with a poor employment history (credits-only claimants) are more likely to claim IB because of a mental health problem. This study has shown a breakdown into 25 categories those claiming IB because of a mental health problem. CONCLUSION DWP data can be used to provide important insights into the trends in reasons for claiming IB, in particular those claiming because of mental health problems. This study also highlighted the growing importance of problems caused by alcohol and drug-abuse claimants, a subset of the mental health category. DWP data should be used at a local as well as a national level to guide and evaluate interventions to help this vulnerable group.

The General Medical Council's Performance Procedures: peer review of performance in the workplace.

The General Medical Council procedures to assess the performance of doctors who may be seriously deficient include peer review of the doctor’s practice at the workplace and tests of competence and skills. Peer reviews are conducted by three trained assessors, two from the same speciality as the doctor being assessed, with one lay assessor. The doctor completes a portfolio to describe his/her training, experience, the circumstances of practice and self rate his/her competence and familiarity in dealing with the common problems of his/her own discipline. The assessment includes a review of the doctor’s medical records; discussion of cases selected from these records; observation of consultations for clinicians, or of relevant activities in non‐clinicians; a tour of the doctor’s workplace; interviews with at least 12 third parties (five nominated by the doctor); and structured interviews with the doctor. The content and structure of the peer review are designed to assess the doctor against the standards defined in Good Medical Practice, as applied to the doctor’s speciality. The assessment methods are based on validated instruments and gather 700–1000 judgements on each doctor. Early experience of the peer review visits has confirmed their feasibility and effectiveness.

Required competencies of occupational physicians: a Delphi survey of UK customers.

Background: Occupational physicians can contribute to good management in healthy enterprises. The requirement to take into account the needs of the customers when planning occupational health services is well established. Aims: To establish the priorities of UK employers, employees, and their representatives regarding the competencies they require from occupational physicians; to explore the reasons for variations of the priorities in different groups; and to make recommendations for occupational medicine training curricula in consideration of these findings. Methods: This study involved a Delphi survey of employers and employees from public and private organisations of varying business sizes, and health and safety specialists as well as trade union representatives throughout the UK. It was conducted in two rounds by a combination of computer assisted telephone interview (CATI) and postal survey techniques, using a questionnaire based on the list of competencies described by UK and European medical training bodies. Results: There was broad consensus about the required competencies of occupational physicians among the respondent subgroups. All the competencies in which occupational physicians are trained were considered important by the customers. In the order of decreasing importance, the competencies were: Law and Ethics, Occupational Hazards, Disability and Fitness for Work, Communication, Environmental Exposures, Research Methods, Health Promotion, and Management. Conclusion: The priorities of customers differed from previously published occupational physicians’ priorities. Existing training programmes for occupational physicians should be regularly reviewed and where necessary, modified to ensure that the emphasis of training meets customer requirements.

A pilot study of the effect of low level exposure to mercury on the health of dental surgeons.

OBJECTIVES--This project was conducted to examine whether the computerised analysis of psychomotor responses available from Cognitive Drug Research is appropriate for measuring an effect of low level exposure to mercury in dentists. METHODS--A computerised battery of psychomotor tests was given to two groups of dentists (older dentists and trainees) and to two age matched control groups. As well as the psychomotor tests, volunteers were required to complete a questionnaire to identify potential influences on psychomotor performance and to provide a sample for analysis of urinary mercury. RESULTS--Statistical analysis of the results showed that the older dentists had slightly higher concentrations of urinary mercury although most were around background levels and they were all within occupational limits. Five of the psychomotor tests showed no differences between the performance of the four groups. The older dentists showed significantly better performance on the simple reaction time test and significantly poorer performance in the immediate word recall and delayed word recall tests. CONCLUSIONS--Poorer performance in memory recall tests confirms previously reported studies. This together with the confirmation that this test system is a practical tool in the occupational setting suggests that a larger study of the effects of mercury exposure on dentists would be appropriate.

Employment status and health: understanding the health of the economically inactive population in Scotland

BackgroundAlthough the association between health and unemployment has been well examined, less attention has been paid to the health of the economically inactive (EI) population. Scotland has one of the worst health records compared to any Western European country and the EI population account for 23% of the working age population. The aim of this study is to investigate and compare the health outcomes and behaviours of the employed, unemployed and the EI populations (further subdivided into the permanently sick, looking after home and family [LAHF] and others) in Scotland.MethodsUsing data from the 2003 Scottish Health Survey, the differences in health and health behaviours among the employed, unemployed and the subgroups of the EI population were examined.ResultsBoth low educational attainment and residence in a deprived community were more likely in the permanently sick group. The LAHF and the unemployed showed worse self-reported health and limiting longstanding illness compared to the employed but no significant differences were observed between these groups. The permanently sick group had significantly poorer health outcomes than all the other economic groups. Similar to the unemployed and LAHF they are more likely to smoke than the employed but less likely (along with LAHF and ‘others’) to exhibit heavy alcohol consumption. Interestingly, the LAHF showed better mental health than the rest of the EI group, but a similar mental health status to the unemployed. On the physical health element of lung function, the LAHF were no worse than the employed.ConclusionWhile on-going health promotion and vocational rehabilitation efforts need to be directed towards all, our data suggests that the EI group is at higher risk and policies and strategies directed at this group may need particular attention.

Predictors of Delayed Return to Work or Job Loss with Respiratory Ill-Health: A Systematic Review

Introduction: Every year approximately 17,000 people in the UK are off work through sickness for six or more weeks. Only fifty percent of those off for six months return to work. Methods: A systematic review was conducted to identify potential risk factors for non-return to work within six to 26 weeks or job loss in adult workers with respiratory ill-health. Twelve databases, citation and author lists and cited references were searched. All abstracts and papers were double read and quality assessed. Main outcome measures were return to work and employment status. Results: Five studies of variable methodological quality were identified, all focussing on asthma, occupationally induced or not, with two single studies also covering chronic obstructive pulmonary disease or rhinitis. In the single study of a general working population, blue collar workers having either asthma or chronic obstructive pulmonary disease, were from two to six times less likely to return to work quickly compared with office workers. Overall, unemployment was high with becoming unemployed three times higher in those with all forms of asthma compared with rhinitis. Also, in those with occupational asthma, job loss was more likely if working in smaller companies and being less well educated. Conclusions: Evidence on predictors for non-return to work or job loss with respiratory ill-health in a general working population is limited. Yet without an understanding of these, interventions to reduce the further step to long term disability cannot be designed and implemented.

Occupational health services now and in the future: the need for a paradigm shift.

Objective: Occupational health services (OHS) evolved in response to the needs of hazardous industries and on the premise that work was harmful. In the developed world, most of these industries have disappeared, and classical occupational diseases are uncommon. Evidence: The evidence now is that most work is safe and safe work is good for health. Access to OHS is inconsistent, and there is no continuity of care for workers who move to another employer or leave work because of ill health. Consensus Process: OHS therefore care for survivor populations and generally those in large enterprises who need OHS the least. From a societal viewpoint, OHS are not fit for purpose. They have not adapted to the evolving small business and more informal work sector. The health impact of long-term worklessness is large and the workless need access to the competencies of OHS. Conclusion: In the future, OHS should develop to meet the needs of the working-age population and to maximize the functional capacity.

Dental practitioners and ill health retirement: causes, outcomes and re-employment

Aim The aim of this project was, by means of a questionnaire to ill health retirees, to determine the factors which have contributed to the premature retirement of general dental practitioners (GDPs) due to ill health.Methods A questionnaire was designed to determine the effects of illness and ill health retirement (IHR) on the lives of those dentists who were affected. This was distributed to 207 dentists who were known to have retired because of ill health but were not suffering from serious, debilitating or life-threatening illnesses.Results A total of 189 questionnaires were returned. The mean age at retirement of respondents was 51.5 years, with a range of 31 to 62 years. Of the respondents, 90% selected general dental practitioner as their last job title. The most common cause of IHR was musculoskeletal disorders (55%), followed by mental and behavioural disorders (28%). A majority of respondents (90%) considered that their ill health was work related. Sixty-three percent of respondents stated that they were able to keep working until their retirement, 34% of respondents stated that they would have liked to have been offered part-time work as an alternative to full retirement, and 27% of dentists reported to have found re-employment since their retirement. In univariate analyses, re-employment of dentists after IHR was significantly associated with age, having dependants, cause of IHR, health having improved and wanting to work again. Multiple logistic regression analyses showed that a combination of age, having dependents and cause of IHR was predictive of re-employment status (p = 0.024).Conclusion This study used a database of dentists who were ill health retired and who were not suffering from life threatening illnesses The results confirmed that the majority were able to work up to their retirement and a similar number would have liked to continue working, particularly if part-time work had been possible. It seems likely that many of the ill health retirees could have been retained in the dental workforce with better support or opportunities for more flexible working.