Health screening clinic to reduce absenteeism and presenteeism among NHS Staff: eTHOS a pilot RCT

Burden and impact of staff sickness absenteeism and presenteeism on the National Health Service and patients

The NHS in the UK is one of the top 10 employers in the world, with 1.3 million employees. 1 However, sickness absenteeism costs the NHS approximately £2.4 billion per year2 (£1 in every £40 of total NHS budget), with an annual average of just under 10 absence days per employee. 3 In 2016, this was 46% higher than other UK industries and 27% higher than the average in the public sector4,5 and is associated with worse patient outcomes, such as increased inpatient mortality, hospital acquired infections, longer bed stays, reduced completion of patient-care tasks and reduced patient satisfaction. 6–10 There is a well-established association between mental ill health among staff, reduced patient satisfaction and increased medication errors. 7–10 Since the start of the COVID-19 pandemic, rates of absenteeism have risen and reports of stress and mental ill health have increased. 1,11,12

A greater potential cost is that of presenteeism (attending work while unwell),13–15 with 44% of NHS staff in 2020 reporting pressure to attend work when feeling unwell,11 with associated reduction in ability to work effectively and negative impact on patients. 8

With greater than ever pressure within the NHS, interventions to tackle the main determinants of work productivity (absenteeism and presenteeism) are increasingly important for staff well-being, improving patient care and for the economy. Estimates suggest that reducing staff absence levels by a third could save 3.4 million working days a year. 16

The health of National Health Service staff

Among NHS hospital staff overall, 44% reported feeling unwell as a result of work-related stress and 29% experienced musculoskeletal problems (MSK) as a result of work activities in the last 12 months. 11 Local surveys indicate that nearly half of hospital staff are overweight or obese, staff generally have low levels of exercise and 10–12% smoke (unpublished local NHS data). 17,18 While the prevalence of cardiovascular disease (CVD) is up to five times greater amongst those over 50 years old, MSK and mental health problems are common across all age groups of NHS staff (unpublished local NHS data). 19

Determinants of absenteeism and presenteeism among National Health Service staff

The main cause of sickness absenteeism in the NHS is mental ill health at 25.4% of all recorded days lost in 2019, nearly double that of 201020 and peaking at 32.4% during the first wave of the COVID-19 pandemic. 21 This is followed by MSK complaints affecting 16%. 22 Poor lifestyle (smoking, lack of physical activity) and overweight/obesity are also important independent determinants of absenteeism and presenteeism,23–27 with CVD being up to five times greater amongst staff over 50 years old (unpublished local NHS data). 19 Absenteeism varies by occupational group, being highest in the lowest-paid (healthcare assistants), professions allied to medicine and infrastructure support staff,28 those working unsocial hours,4,16 and among older workers (unpublished local NHS data). 29 Presenteeism rates follow similar patterns. 30

National Health Service health and well-being policy

In response to the high levels of staff ill health and sickness absenteeism, NHS England created a ‘Healthy Workforce Programme’, supported by the Royal College of Physicians,31 with a £450 million financial incentive for Trusts to improve staff health and well-being and thereby patient care. 32 Key actions included making the NHS CVD health check (for those aged 40–74 years without pre-existing diabetes or CVD)33 more accessible for staff in the workplace and improving access to physiotherapy, mental health, weight management and smoking cessation services. 34 In most hospitals, occupational health services, which are often outsourced, do not have a preventive or well-being role and therefore new initiatives are required. Since then, mainly in response to staff need during the pandemic, NHS hospitals have implemented a variety of health and well-being initiatives, although most are focused on mental well-being, are likely to be short term and have yet to be thoroughly evaluated. 35,36

Recommended interventions for identification and management of mental health, musculoskeletal health and cardiovascular disease in the general population

Workplace interventions to address absenteeism and presenteeism

There are several systematic reviews and many individual studies which evaluate the effectiveness of workplace health promotion or return-to-work programmes,24,52–54 but few are conducted among healthcare staff, and they rarely consider impact on absenteeism or presenteeism, or include a control group. Most interventions for healthcare staff are aimed at promoting mental health and well-being. 55

Of most relevance, an evaluation of health screening specifically targeted to 635 low-paid government workers aged 40 and over using the NHS health check with referral to appropriate interventions56 showed improvement in most markers of cardiovascular health after 9 months, although attendance rates were relatively low (20%).

In another feasibility study, 253 hospital employees attended a workplace CVD health check in three NHS hospital sites, received tailored advice, signposting to health-related information, relevant free services and advice to visit their general practitioner (GP) where appropriate. 52 Forty-seven per cent were overweight/obese and many reported existing health problems. Participants perceived the clinic to be convenient, informative and useful for raising awareness of health issues. After 5 weeks, they reported dietary changes (41%); increase in physical activity (30%); smokers reported quitting/cutting down (44%) and those exceeding alcohol limits reported cutting consumption (48%). Fifty-three per cent of those advised to visit their GP complied.

No studies have, however, evaluated the cost effectiveness of interventions targeted at screening for and early management of the main causes of sickness absenteeism in healthcare settings – essential evidence before Trusts will invest limited healthcare resources. The evidence available reinforces the need to focus on high-risk groups, provide interventions of sufficient intensity and optimise attendance to maximise the chances of interventions being effective. 57,58 The most effective model is likely to be a combination of health screening and health/wellness programmes with targeted interventions. 59

Based on learning from a recent pilot staff health screening clinic (SHSC) set up at Queen Elizabeth Hospital Birmingham (QEHB), we have developed a health screening service, including pathways for direct invitation, assessment for MSK, mental health and CVD problems (the three major causes of staff absenteeism) and onward referral, for hospital employees.

We present the results of a pilot randomised controlled trial (RCT) to assess the feasibility of conducting a full RCT to evaluate the effectiveness and cost effectiveness of this service in reducing absenteeism and presenteeism within NHS hospitals.

Setting

The trial was conducted in three large urban hospitals and one rural district general hospital within three NHS Hospital Trusts in the West Midlands (see Table 1), allowing the testing of practical aspects in a range of sites.

Eligibility criteria

All employees in the participating hospitals who were able to provide informed consent were eligible to participate except those who had previously attended a pilot health screening clinic at QEHB or who were currently taking part in another drug trial (with the exception of COVID-related drugs/vaccines) or health and well-being trial.

Recruitment

Recruitment occurred in several phases, aiming to reflect the workforce characteristics of each hospital. Anonymous human resources (HR) data providing sociodemographic and occupational characteristics were obtained to choose wards which reflected the characteristics of the whole hospital population. Posters advertising the trial were displayed in departments/wards for a minimum of 2 weeks (or more if local arrangements required) before invitations were sent out, during which time staff could request not to receive an invitation. In order to be accessible to the full workforce, participants were informed of the trial through staff meetings, noticeboards and ward champions, and invited through multiple approaches including e-mail and personal invitation. Reminder letters were sent to non-responders after 2 weeks, with up to two further reminders if necessary. Local staff were engaged to raise trial awareness and arrange cover to allow attendance at the health screening clinic.

Consent

Potential participants joined the trial via a weblink to a custom-designed electronic trial data collection platform hosted by the Birmingham Clinical Trials Unit (BCTU). Those with limited access to the internet could complete a paper-based expression of interest through the internal mail system, then attend the clinic to complete consent and other forms online. Consent was obtained through the trial platform, via participants’ own electronic devices or using tablets provided to the health screening clinic staff, and ongoing consent was confirmed at each follow-up point. The participant information sheet (was provided with the initial invitation and was also available on the trial platform). Participants could contact the research team by telephone or request contact from the research team via the trial platform to ask any questions.

Intervention arm

Participants received an invitation to a SHSC, available during or outside work time (generally 7 a.m.–5 p.m., Monday–Friday), administered by trained clinic nurses [hereafter known as enhancing the Health of NHS Staff (eTHOS) nurses]. A maximum of three attempts was made to contact participants to arrange an appointment. The screening appointment consisted of two stages: (1) screening assessment for three components: mental health, MSK health and finally cardiovascular health, followed by (2) advice and/or referral, according to level of risk, to appropriate services for management according to NHS/NICE recommendations (see Figure 2). The screening assessment was delivered by nurses, with consultant physician oversight at each centre, supported by a standardised protocol and prompts from the electronic data platform. All data from participants were entered directly onto the electronic platform in a paperless system.

FIGURE 1.

Overview of staff health screening intervention. From National Institute for Health and Care Excellence 2016. 60

The eTHOS nurses explained the screening scores to participants and, where applicable, any recommended actions. Local pathways were used; these included self-referral to the staff physiotherapy service, local mental health support (e.g. healthy minds, Frontline19), lifestyle changes as directed in appropriate leaflets and websites, advice to visit their GP, recommendations to the GP that a direct referral be made for the participant and/or a request that the GP arrange a follow-up appointment with the participant. Where there were concerns regarding safety, the eTHOS nurse would immediately inform the local site principal investigator (PI) who would then contact the GP.

Participants reporting relevant diagnosed conditions currently being treated did not receive the referral element of that component. A results letter detailing findings and recommendations was sent to participants and their GPs for appropriate action.

Primary outcomes and stop/go criteria

Three coprimary outcomes were originally planned to inform criteria to progress to the definitive trial:

• Recruitment (consented) as a proportion of those invited.

• Referral to any recommended services as a result of the three screening components (usually GP, local physiotherapy/community psychological services) – intervention arm only.

• Attendance at any recommended services at 26 weeks (self-report) – intervention arm only.

We defined ‘referral’ as anyone who was eligible for a referral, that is, they recorded a suitable risk value and were not already being treated for that condition.

Due to additional pandemic-related delays, following discussions with the funder, it was agreed not to extend the duration of the trial in order to complete follow-up of all participants to 6 months. This meant that only a small number of participants reached the 26-week follow-up assessment, leaving limited data available to reliably assess the third coprimary outcome on attendance. After discussion with the Trial Oversight Committee (TOC), it was agreed that acceptance of the referral (signifying intention) which was collected during the screening assessment, should be used as a proxy for attendance.

The decision to continue to a full trial was informed by progression criteria using a traffic light system as guidance (see Table 2), with flexibility built in to allow for uncertainty in cost effectiveness despite either low participation, referral or attendance rates. The three coprimary outcomes formed stop/go criteria when considered together. If any of these values fell into the ‘amber’ zone, then the trial would require modifications to proceed to full trial. If all were ‘red’, then the trial would be considered unfeasible.

Secondary outcomes were collected to inform the design of the definitive RCT and any modifications required:

Secondary outcomes

• Comparison of baseline characteristics of included participants and hospital population for assessing generalisability.

• Description of the results of the intervention screening assessments.

• Number and type of referrals to recommended services (intervention arm only).

• Attendance at each individual recommended service (acceptance of referral during screening assessment, self-report at 26 weeks; intervention arm only).

• Lifestyle relevant to screening intervention advice and referrals (self-report at 26 weeks compared with baseline) including Physical Activity Index measuring exercise levels (GPPAQ),64 smoking status, weight (kg).

• Acceptability of intervention to participants and health screening clinic staff (interviews within the Process Evaluation).

• Feasibility of trial processes (completeness of relevant data items, interviews).

• Indication of contamination (comparing pre/post data for health behaviours and health care/other service utilisation in control arm).

Outcomes related to the definitive trial

• Sickness absenteeism at 26 weeks with reasons, measured by days and spells:

  • self-report absolute absenteeism, relative absenteeism and relative hours of work – for last 7 days and last 28 days [World Health Organization Health and Work Performance Questionnaire (WHO-HPQ)]69

  • self-report absenteeism using 6-month recall period

  • employee records of absenteeism, which will be the primary outcome of the definitive trial. Routinely collected data from the NHS Electronic Staff Record Programme, linked to employee ID.

• Presenteeism at 26 weeks [self-report absolute presenteeism and relative presenteeism for last 28 days (WHO-HPQ)]. 69

• Attendance at occupational health service at 26 weeks (self-report).

• Healthcare utilisation at 26 weeks (self-report) including GP consultations and hospital admissions.

• EuroQol-5 Dimensions, five-level version (EQ-5D-5L) index value measuring health-related quality of life (HRQoL) (EuroQol EQ-5D 5-level)70 at 26 weeks.

• Resource use and costs collected by self-report questionnaire to participants on health service utilisation and information from the screening assessment regarding duration and resources used.

Primary outcomes

Recruitment rate was calculated in two ways:

• percentage of invited employees that consented to take part in the trial with 95% CI

• percentage of invited employees who were randomised into the trial with 95% CIs.

Referral to a service was calculated as the percentage (with 95% CI) of participants randomised to the intervention arm that were eligible for a referral to any of the specified services (GP, physiotherapy, community psychological services). Participants were eligible for a referral if they met the score requirement for any of the mental health, MSK or cardiovascular health check assessments and were not already being treated for the referring concern.

As there were few follow-up data on self-reported attendance at referrals (because of resources restrictions forcing early trial closure), attendance at any recommended service was estimated by self-reported ‘intention’ (as agreed with the TOC). During the intervention screening, participants were given the option to accept or reject a referral to any service. The estimate of attendance at any recommended service was then determined by the proportion of participants in the intervention arm eligible for a referral that accepted that referral and presented as a percentage with 95% CI. Data from the 26-week follow-up questionnaires are provided in Appendix 2.

Secondary outcomes

Analyses were mainly descriptive, summarising binary outcomes using number of responses with percentages, and continuous outcomes with means and SDs, or medians and interquartile ranges as appropriate. No statistical modelling was undertaken, and no p-values are reported. No subgroup analyses were planned for this feasibility study.

Quantitative data collection and analysis

Quantitative data to support the process evaluation were obtained from:

• Recruitment and intervention data, for example, response rate; proportions of those invited consenting, being randomised and attending the screening.

• Baseline questionnaire to assess characteristics, for example, age, ethnicity, marital status, Index of Multiple Deprivation, educational attainment and employment role of the employees recruited to study (programme reach). We also obtained hospital-level HR data to compare the characteristics of those invited and those consenting with the whole hospital populations.

• Logs kept by the staff health screening programme recording attendance, trial database records of screening tests undertaken and duration of contacts (fidelity).

• Healthcare issues identified at the employee screening, and referrals made to GP and other services (fidelity).

• Self-report of attendance, and intention to attend at recommended services from intervention screening and 26-week follow-up questionnaire (uptake).

• Brief questionnaire at eligibility stage to staff not taking up the offer of the study to ascertain reasons for not participating (reach).

Findings were presented with descriptive statistics.

Qualitative data collection and analysis

Resource use

All participating centres were contacted to collect information on their estimated time taken for each screening clinic task, the grade of the member of staff responsible and the cost of the individual blood tests. Responses were collated and a typical duration for each task was agreed upon by the study team. The amount of staff time required for each screening task was then multiplied by the relevant unit costs obtained from standard sources74 (see Table 6). Unit costs are shown in Tables 6 and 7.

Costs

The cost of screening included the cost of staff time to undertake all tasks and the cost of blood tests. The total cost of blood tests per participant was weighted taking into account the proportion who received each type of blood test. Those tasks that were directly related to processing and reporting blood tests were only applied to the proportion who had at least one blood test. Costs were only applied to those who actually attended screening.

Certain tasks could be performed by healthcare professionals of different pay bands (e.g. a nurse, band 5; a nurse specialist, band 6; or a healthcare assistant, band 2 or 3). Analysis was undertaken so that the cost of screening per participant could be presented for all possible combinations, including the highest possible cost (where all tasks are carried out by the higher potential pay bands) and the lowest possible cost (for the lower pay bands).

Quality of life

The EQ-5D-5L questionnaire, containing five dimensions (mobility, self-care, usual activities, pain and discomfort, anxiety and depression), was given to participants to complete at baseline and responses were valued using the cross-walk algorithm. 75 Descriptive analysis was undertaken to calculate the mean, SD and range of the overall EQ-5D-5L score, and also the frequency of responses within each dimension.

Recruitment

Three hundred and fourteen of the 3788 invited staff gave their consent to take part in the trial, which equated to 8.3% (95% CI 7.4% to 9.2%) of those invited, which met the red stop/go criterion for this outcome (see Table 15). Of the 314, 236 were randomised, which equated to 6.2% (95% CI 5.5% to 7.0%) of those invited.

Referral

Fifty-seven of 118 [48.3% (95%CI 39.0% to 57.7%)] participants randomised to the intervention arm were eligible for referral to at least one service (GP, local psychological or physiotherapy services), which met the green stop/go criterion.

Attendance at referrals

Attendance data for this outcome are presented here as the agreed proxy outcome (intention to attend). During the intervention, 18 of the 57 participants accepted a referral to at least one service. This equated to 31.6% (95% CI 19.9% to 45.2%) of those eligible for referral and met the amber stop–go progression criterion, although the CIs are wide, spanning both the red and green criteria.

Due to the database structure, we were unable to determine whether five of those eligible for a psychological referral confirmed attendance. In the above estimates, we have used a conservative approach and assumed all five participants did not accept a referral. Similarly, six participants eligible for a GP referral from HbA1c, cholesterol, eGFR and QRISK2 components were not offered a referral and all six were assumed not to have accepted. However, if we assume all 10 accepted a referral (as one participant already accepts a referral from another component), then 28/57 participants accepted a referral in total, which equates to 49.1% (95% CI 35.6% to 62.7%) (still in the amber category).

Overall, the stop/go criteria were in the red, green and amber zones (Table 15); therefore, the TOC recommended that a full-scale trial should proceed, but with modifications drawn from the findings of the secondary outcomes and process evaluation (see later).

Assessing generalisability (programme reach)

Table 16 compares the demographics of the hospital, invited and randomised populations. The selected invited population was similar to the hospital population, reflecting the full range of characteristics. However, the participants who responded and eventually took part in the trial were slightly more likely to be female, but more likely to be white British (78.0% compared to 59.7%), allied health professionals (14.0% compared to 6.9%) and healthcare scientists (11.9% compared to 5.0%). They were less likely to be from estates and ancillary (2.5% compared to 4.7%), medical and dental (5.5% compared to 11.9%) and nursing and midwifery registered staff groups (26.7% compared to 33.4%). Generalisability could be improved.

Results of intervention screening assessments

Details of subsequent referrals needed

Many (n = 62; 61.4%) of the 101 intervention participants who completed the intervention met criteria for referral to at least one service (see Table 20). Five participants were already being treated for all components requiring a referral, meaning 57 (56.4%) were eligible for referral to at least one service; 46 (45.5%) participants were eligible for referral to their GP (14 accepted), 10 (9.9%) to local psychological services (1 accepted) and 17 (16.8%) to physiotherapy (4 accepted).

Outcomes at 26 weeks

Very limited data were collected at the 26-week follow-up as only 26 people had reached that time point (after three withdrawals). However, only four completed the questionnaires in the intervention arm and three in the usual care arm. This precluded meaningful analyses of attendance at referred services, changes in lifestyle, quality of life, healthcare utilisation, absenteeism, presenteeism, assessment of contamination and any indication of effect size (SD) for the definitive trial; however, data tables are presented in Appendix 2 for completeness. HR sickness absence records 26 weeks after randomisation were available for all 26 participants.

Completeness of data items and attendance at screening clinic (fidelity)

One hundred and eighteen participants in each arm completed the baseline questionnaire and were randomised, 101 participants completed the initial self-completion screening questionnaires prior to the screening clinic and of those, 102 nurse-intervention forms were completed. Individual data items were generally well completed with few missing data, especially for the intervention screening data. A sample of clinic logs indicated low deoxyribonucleic acid (DNA) rates. Duration of screening sessions is presented in the health economics section below.

Resource use

The base-case times for each screening task, grades of staff responsible for each task and disaggregated costs per task are presented in Table 21. Tasks were related to contacting the participant to book the appointment, clinic tasks for all participants (paperwork, greeting the participant and completing the screening), tasks relevant for those who required blood tests, and production of GP results/referral letters.

Out of 118 intervention arm participants, 101 actually attended screening and 56 (55.4%) received at least one blood test. Using the cost of each blood test and the proportion receiving each test, the average cost of blood tests per participant was calculated as £3.29 (Table 22).

As previously calculated, 55.4% of participants received at least one blood test. Therefore, any costs associated with tasks for blood tests were only included for this proportion of the participants. Table 23 shows the weighted cost of each task for each combination of staff grade.

The overall maximum screening cost per participant (including blood tests) was £107.48 if the highest band staff were used and £99.98 if the lowest band staff ran the clinic (Table 24).

Quality of life

Complete EQ-5D-5L data were available for 233/236 participants randomised (response rate 98.7%). The mean score was 0.793 (SD 0.168) with a range from 0.0140 to 1.000 (see Table 11). The responses for each dimension can be found in Figure 5. This shows that participants reported few problems with mobility, self-care or usual activities. However, 22.8% reported at least moderate pain or discomfort and 18.9% were at least moderately anxious or depressed.

FIGURE 5.

Distribution of scores by EQ-5D domains.

Participant recruitment

Recruitment to the qualitative part of the process evaluation occurred during the second wave of trial recruitment, between July and October 2021. We conducted 51 (63.8%) out of the 80 interviews originally planned (see Table 25).

Participant characteristics

The largest planned group was the trial participants. Ninety-three participants were invited to participate, of whom 31 responded and were interviewed. The length of interviews varied from 10 to 40 minutes depending on their category. All interviews (and consent) were conducted online.

Demographic characteristics of the trial participants included in the interviews (age, sex, ethnicity, usual hours) broadly matched those of the distribution within the trial (see Table 26). However, the sample was not distributed across the four sites as originally intended and our interview sample contains proportionately more registered nurses and midwives. We did not have the opportunity to purposively sample interviewees as intended because of a low response rate, marked reduction of the recruitment period (4 months instead of 18 months), sites commencing the study at different times and the need to allow sufficient time between consenting to the main trial and invitation to participate in the qualitative substudy.

Although we were able to interview the full complement of nurses delivering the intervention, due to the compressed time frame and service restrictions during the pandemic, we were limited in recruitment of providers receiving referrals, finally interviewing three physios and one GP. Table 27 provides a summary of the type and size of outside agencies spoken with.

The remainder of this chapter presents the data from the qualitative interviews supported by interviewee quotes (see Box 1 for key to participant identifiers). The data are organised under participant type (trial participant, eTHOS nurse, service provider and outside agencies).

Table 28 lists the topics covered in each section and summarises the key findings within the data. A summary of the cross-cutting themes arising from these data can be found in ‘Cross-cutting themes’.

Intervention acceptability

We present this topic within the trial participant feedback first as it sets the context for all other aspects of the evaluation. Furthermore, it was very difficult to disentangle participants’ views of the concept of health screening from their evaluation of the screening programme (intervention) itself.

Satisfaction with the content and concept

The word cloud (see Figure 6) was generated with the qualitative analysis software NVivo. It captured key words used in the positive feedback regarding the intervention; the font sizes used depict the frequency of use (the larger the word, the more frequently it was used).

FIGURE 6.

Trial participants’ evaluation of the intervention.

As can be seen, it was well received, participants could see its long-term value in improving sickness absence and staff retention:

good that we’re now looking at reasons why, and different factors that might affect someone … a lot of people … tend to ignore their own health … until they’re forced to pay attention to it. So trialling something like a health check is beneficial.

P10

The intervention provided NHS staff with an opportunity to access health care that they could not otherwise obtain; this opportunity was highly valued and is explained further below. In addition, one trial participant explained how important it was to have a space where staff, who are focused on other people’s needs, can actually talk about their own needs, and reflect on their own lifestyles: ‘nice to have a chat with somebody about your health, about you … in a healthcare setting it’s sometimes all about other people’ (P8).

It was recognised that while findings from the intervention might, in the short term, increase time away from work for conditions that people had not previously been aware of, the benefits of having these conditions treated early was more important: ‘if anything was picked up nice and early then it’s obviously going to help the NHS isn’t it?’ (P16).

The intervention was seen as a good vehicle for improving health, and this in turn could boost staff morale: ‘I think it’s likely to improve morale, I think it’s likely to improve the fitness of the workforce and therefore their happiness’ (P18).

The pandemic had heightened the need for this: ‘Especially with COVID the sense of the stress on the wards that’s quite sad to see’ (eN8).

The non-judgemental delivery of the findings and subsequent recommendations was also valued: ‘the face-to-face thing isn’t somebody telling you off or judging you, or giving you set goals’ (P16).

This quote summarises the positive feedback well: ‘I felt like it was exactly what I needed at that time, and I am thankful that I did partake in it’ (P11).

Summary: intervention acceptability

There was much gratitude regarding the opportunity to participate in the intervention, particularly in the light of COVID-19, the experiences of which prompted a demand for mental health screening tools addressing work-related stress. However, some participants also had expectations that went beyond the scope of what screening tools can offer.

Motivation to participate

When participants were asked why they had signed up for the study, there was repeated reference to the barriers they faced when trying to get appointments with their GP. Trial participants explained how difficult it was trying to contact and arrange GP appointments around their shifts. The intervention was therefore seen as a welcome alternative to contacting the GP:

One morning I was coming out of work I decide to phone [for a GP appt] as soon as I leave the building, and I walk home, which is half an hour, and maybe two minutes after reaching [home] then somebody was there, I was 90 something in queue … to speak to a practice nurse, and you couldn’t get appointment … so that’s exactly why I don’t really go to the doctor very often.

P2

It seemed that some trial participants also signed up for the study because they expected to be able to access support more quickly through this route: ‘They think they come in here because they are going to get some sort of fast track treatment’ (RN5).

For some, there was also a reluctance to see their GP unless it was really urgent.

I am not a GP person, I tend not to go to GPs. I fully appreciate how busy they are and the importance of the work they do so I do tend to self-remedy if there is anything problematic, I certainly haven’t been to my GP with neck, shoulder and back pain because I know exactly what they are going to tell me to do anyway, go to a physio, so I haven’t bothered them.

P11

However, these obstacles to attending the GP may have resulted in some participants having unrealistic expectations about what the screening involved. Some viewed it as equivalent to a GP appointment expecting to be examined or invited to set their own agenda for discussion: ‘There was no, “So what brought you here, what were you hoping to get out of this, what issues have you been having that prompted you to come?”’ (P10).

And some gave the impression that they viewed the intervention as an assessment of all aspects of their health, rather than one that was limited to the three specific components screened for:

I suffer with an underactive thyroid … and I thought well it would probably be a good thing to just have an update really and see what’s going on, and see if you guys, I don’t know, pick up anything that hadn’t been picked up.

P20

The irony of not having time to attend the GP was also highlighted: ‘Staff that say they’re too busy to go to the GP … but they call in sick’ (P14).

Finally, participants hoped that the data would be harnessed to justify elements of positive changes in the workplace:

To help the big managers realise it’s not just people moaning, that there is actual health things … some evidence behind it … You just feel like work is so busy nobody has got time to listen to your problems, you’ve just got to get on and do the job.

P27

Summary: motivation to participate

Key motivators for participation were the hope that the research would lead to positive changes in the workplace, and as an alternative to attending a GP appointment – particularly given the increased access issues within the pandemic.

Trial processes

Usual care arm

Barriers and facilitators to attendance

Reasons for not attending

No written feedback was received for those who did not attend their screening appointment. The two participants who agreed to be interviewed explained that multiple factors had prevented them from attending. One had been unable to attend their appointment or reschedule it because of sick leave. The other was unable to get away from work on the day of the scheduled appointment and could not reschedule due to annual leave followed by sick leave. Both would have liked to reschedule if the trial had not closed.

These participants did not live locally and the location of the clinic was a further barrier to them rescheduling. For one, an alternative place of their choosing would have been more acceptable. In addition, both made the unprompted suggestion that a virtual appointment (phone call or online) would have made attending easier: ‘Or like I say whether it could all be completed online or something like that, because that just gives another option to let people get involved with it’ (P30).

However, another participant recognised that, although some would not like this option, it potentially had additional advantages for some:

Everything is online. It’s easier to talk to someone online … some people find it easier to talk to a randomer on the computer about their life, then other people … might find it less caring if there’s not a human in the room with them. So I reckon that works both ways … It’s not like you’re telling someone they have got cancer or anything.

P21

Telehealth was also brought up by the service providers (physios and GPs). While the COVID-19 pandemic had provided an opportunity for people to recognise the benefits of telehealth, it had, at times, increased staff workload. And there are some things that are understandably very hard to assess virtually. At least one Trust had been unable to make sufficient investments in technology to facilitate telehealth.

Confidentiality

Trial participants on the whole expressed little concern about confidentiality in relation to screening. For some, there was a cultural expectation that confidentiality would be upheld by healthcare professionals during appointments, putting them at ease: ‘You’re dealing with people who have to have privacy at their heart all the time because they are dealing with patients and parents, so actually I didn’t even give that a second thought, no’ (P8).

Knowledge of research processes was also reported as reassurance that confidentiality will be upheld (a number of interviewees participated because they had previous experience of working in research):

Not really because I’ve done some research stuff before, like learning about research, so I knew that it wasn’t going to, they can’t just disclose stuff to my employer, and it was run by the university rather than my work, so I didn’t feel like there was going to be any repercussions or anything, like it was going to go in my file or anything like that.

P11

Good relationships with line managers were cited when rationalising a lack of concern about confidentiality:

But I have a really good relationship with my line manager and my team anyway, so we’re only a really small unit, so I don’t know if that makes a difference, there’s only 16 of us, so for me personally no, it wouldn’t.

P14

Line manager knowledge was not a requirement of eTHOS, something which appealed to a minority of employees, and was reported to be a positive of the intervention:

I think it’s very confidential, I think it’s the best way, because through occupational health, I got referral through occupational health, but my manager knew all about that, so she had the letter about it and what I told occupational health, so I don’t like that aspect of it. So I think I feel that this trial is very confidential, and you feel safe there.

P13

However, some participants felt that line manager knowledge and support for staff screening was key if changes to working conditions are to be made, to help resolve any health issues contributed to by the workplace:

I think your employer should know if there’s certain things that have been found in a health check. I think that working for someone like the NHS is they are very hot on that stuff so if you do have even mental or physical issues I think there’s a lot in place that can help people.

P10

eTHOS nurses reported that in specific cases staff may be concerned or may feel uncomfortable with screening, if, for example, the screening nurse was managed by them:

We’ve got a proportion of people that are in that situation that they have half changed their mind because they have realised that it would be potential discussing with colleagues. My line manager, for example, half completed and then has stopped, so it may be that they don’t feel that it’s clinically appropriate or professionally appropriate.

eN6

Of the staff who decided to attend screening in their own time, only one reported doing so out of concerns for their privacy: ‘In intensive care I would also have had to have probably tell somebody where I am going and I didn’t want to have to explain I had an appointment, and it was easier to just do on my day off’ (P13).

Role of occupational health

The role of occupational health tended to be summarised in contrast to the eTHOS intervention, as a service designed to tackle pre-existing issues:

Occupational health is there, but that’s more if you have issues, once the issue has actually arisen, as opposed to looking at preventative care in a screening and potentially getting you to change your lifestyle before things become problematic.

P12

Employee participants felt there were question marks over whether occupational health services would have the capacity to host health screening. Services were already perceived to be stretched: ‘Well I suppose I know from referring staff for occupational health appointments they are inundated and swamped, and whether they would be able to do that I don’t know’ (P16).

The current pandemic was seen to be exacerbating pressures on occupational health capacity:

Because of COVID there was a triage going on so getting seen by occupational health has been a job and a half, which COVID has had a lot to answer for left, right and centre hasn’t it? But it was a lot more difficult to get seen than it was previously, and they haven’t done a lot of referring to other places.

P19

A minority of staff reported dissatisfaction with previous occupational health engagement, with one interviewee reporting the workplace changes as being minimal, and another that they were obstructive:

They seem to moan and not want to turn up to stuff. I don’t know, I used to work at a different hospital and their occupational health seemed to be quite good, whereas the one at this Trust, I just think it’s, ‘Stay away,’ they don’t see very caring towards staff … they are just obstructive sometimes.

P21

The lack of need to be referred by a line manager was seen by some interviewees as a benefit to eTHOS, concerns were raised with regard to personal health issues being shared by others in the workplace (P13 on p 62) and negatively impacting future job applications:

One of the things would be depends who it [the screening] was run by and their perception of the confidentiality and whether it would then go against them say if they were going to apply for another job later down the line [e.g. because of] back pain.

P11

However, interviewees did not specifically raise a lack of confidentiality as a reason to avoid occupational health referral. The majority of interviewees reported a good relationship with their line manager and had no concerns about personal health data being shared with them specifically: ‘No, I don’t think so. I am quite open with my manager anyway’ (P27).

The eTHOS nurses at one of the sites felt that staff were fully aware of and how to get an occupational health referral. However, this was not necessarily the case: ‘I wouldn’t know how to contact them to be honest. I tried to contact them to rearrange an appointment or something and I couldn’t find the number, and it’s really difficult’ (P28).

Those at the other sites did not comment and were not directly asked. eTHOS nurses (in contrast to trial participants) reported that some participants did not want occupational health referrals in the context of explaining that line managers would be informed of such a referral:

I have had a couple of the questions have been, ‘Do you want me to refer you to occupational health?’ And then there’s this spiel about if we refer you to occupational health your manager will be informed and can access what is said, and they haven’t wanted to.

eN1

Response to referral recommendations

The types of referrals and recommendations that participants might have received are described in Intervention arm. As we were unable to collect 6-month follow-up data to assess uptake of referral recommendations, we explored this in depth in the qualitative interviews.

Training

The training was described as ‘good’ (eN8) ‘fine’ (eN3), ‘great’ (eN2) and the eTHOS nurses had felt well supported throughout.

There were, however, things that might have made the delivery easier from the outset and which would be needed if going to full trial and being rolled out to new sites. The opportunity to practise on a ‘dummy’ participant as part of the training would have been highly valued. The importance of experience in delivering the intervention was also evidenced by the fact that support from colleagues who had been running the ‘Staff Well’ clinic was found by one site to have been ‘[v]ery useful’ (eN1).

These two sites seemed to have had less concerns than the two who had not been able to access such support. Training needs were exacerbated by the fact that the trial was paused shortly after training, during which time there were a lot of staff changes.

What was most needed was better preparation for communicating and managing high scores in the screening tools. This was most evident when communicating results relating to mental health, obesity and alcohol: ‘I didn’t find it difficult to explain, more [it was] … the emotive side … [that was] difficult to deliver rather than the explanation’ (eN5).

As eN5 trailed off, eN6 joined in saying:

Explaining that your cholesterol is potentially high because … your BMI is obese … and all of that it’s just an uncomfortable type of situation … It could be somebody a lot more senior than you, or a close colleague.

eN6

And from another site: ‘Some things I just didn’t know … especially when it’s all the mental health side of things I felt a bit out of my depth really’ (eN4).

It was suggested that a clear standard operating procedure might have been of benefit.

Equally important though was the need for a distress pathway to support the eTHOS nurses with the management of participants’ mental health concerns which were at times distressing, not just for the trial participants, but for the nurses delivering the intervention too:

‘The care for my team as well. This is an emotive topic, and they’re going to take on some of this’ (eN6).

Acceptability of concept

Absenteeism was recognised as an important issue, and the intervention’s attempt to address this perceived as being a step in the right direction:

It is needed, there are massive issues even within small departments, and the impact it has, sickness rates, is phenomenal. We can see that in our own department, so if you take that on as the whole NHS it’s a massive problem.

eN6

Staff participating in the trial had reported to the eTHOS nurses that the intervention made them feel appreciated, seeing it as a way of the Trust demonstrating that they valued their staff: ‘They appreciate that the employer is doing something for them, so they can be able to get an assessment of their well-being at work’ [eN2 (from a different site to P18 p. 52)].

One of the eTHOS nurses also highlighted the irony that some private companies offer their staff annual health checks whereas the NHS does not, despite the need. It was also mentioned that for some employees, discussing their own health within their workplace was perceived as ‘taboo’; therefore, providing a staff space for them to do so was seen as a positive: ‘Some of these subjects are quite taboo … so if it’s raised with them and it’s there, they feel more comfortable to do that’ (eN5).

However, despite these positives, eTHOS nurses from some of the sites had important concerns about the intervention – that it fell short of what staff were expecting. These eTHOS nurses were concerned that they were not able to offer the information or services needed to truly help people:

I felt slightly embarrassed … that they have come with GAD scores of X amount and they are telling us that they have had suicidal thoughts for 20 years, and there’s still nothing that anybody can do, and I go, ‘Here’s a leaflet, thanks for your time.’ … we just feel like we’re just scratching the surface, and we’re putting another sticky plaster over a situation.

eN6

I could only offer what she already knew and what already didn’t meet her needs.

eN4 (from a different site)

We felt that these sentiments were crucial and have used the term ‘sticking plaster’ in our cross-cutting themes.

To further elaborate, examples of participant feedback were given and additional concern expressed that over time, this could result in a decline in staff interest in the intervention:

We’ve had participants say, ‘No I won’t take the leaflets because I’ve had all them ten times.’ … I think it just needs a lot of input … [or people will say], ‘Actually it’s not achieving anything, I wouldn’t bother going now we know that. What’s the point of going to occupational health, or whatever? There’s no point going to your GP because you are just going to get fobbed off, you’re going to wait a year for some physio.’

eN6

It was suggested that a more cost-effective way of achieving the intervention’s goals would be to: ‘Just [run] a good Well-being campaign within each Trust? … people could probably Google mental health services within your local area and find Healthy Minds for example’ (eN6).

In addition, when asked, the eTHOS nurses confirmed that there were also examples of workplace culture being behind health concerns:

I saw a woman this morning and she’s working 60 hours a week being paid 37½, … it’s not good for your health … it’s what’s expected, or her words were, ‘They don’t understand what we do, the executive level don’t understand how people are working, and what needs to be done.’

eN8

Intervention delivery experience

The eTHOS nurses talked favourably about the departmental visits, commenting on the importance of making pre-arranged appointments. However, sometimes it had been difficult to identify who was the most appropriate contact for each department; therefore, visits had been easier with those departments known to them. Wards had been less receptive than other departments due to the nature of their work making it difficult to leave the patients in their care.

On the other hand, the eTHOS nurses also described how the pandemic had complicated the study or made it more challenging. Changes to staff working patterns rendered recruitment problematic:

The recruitment I think is quite difficult going out and trying to encourage people to come in, been a bit, and whether that’s more to do with actually the time that we’re trying to do that with lockdowns and the staff redeployment, and then units reopening and then having a huge workload that they are trying to get people back in whilst also having staff shortages it has been quite difficult.

eN4

The forced postponement of eTHOS due to the pandemic was also reported to have reduced the momentum of the research:

The stopping and starting that we had because of COVID didn’t help, we half got going and then you would stop for a few months, and then we had to pick it back up again. So it’s going back to day one again, so that was also a challenge.

eN6

On a more positive note, eTHOS nurses from one site felt the pandemic had normalised research on wards due to the large amount of rapid response COVID-19 research being conducted, encouraging eTHOS participation:

I think research in general at the moment is very much in the news, and it’s very, they have been so used to seeing research nurses on the wards that we did go for COVID trials or whatever, had we done it pre-COVID.

eN1

The eTHOS nurses described the trial participants as ‘[f]orthcoming’ (eN2).

And they ‘[l]ove[d] the online consenting’ (eN1).

When it came to the actual delivery of the intervention, some of the eTHOS nurses considered it to be ‘[b]read and butter’ (eN6).

Whereas others found that as time went on and they obtained more experience it ‘[g]ot better’ (eN3).

For some there was a sense that the appointments sometimes needed ‘[p]ad[ding] out’ (eN1).

A varying, wide range of information and services were available at the different sites. The eTHOS nurses found that it was most useful to have gone through the information in advance so that they were familiar with their content and could then go through them with the participant.

While, on the one hand, having all the required responses available to read out from the database meant they could ‘[j]ust follow REDCap’ (eN4).

On the other hand, they also found it useful to paraphrase the text in the database: ‘You can just read it off the computer, off the database if you want, but that never feels particularly comfortable for me’ (eN8).

There were also occasions when the eTHOS nurses found the need to use clinical judgement which the database did not facilitate, that is, if there was an explanation for a participant’s high results negating the need for further intervention, for example, recent bereavement or bradycardia in a triathlete.

Finally, one site also had concerns about difficult disclosures relating to colleagues:

One of the nurses … was put in quite an uncomfortable situation, because they were talking about bullying and harassment that’s been going on in the workplace, and the participant was giving names of staff that the nurse works with, it’s not in [our unit], but … if you work here long enough there’s a good chance that you know quite a few people. So the nurse felt uncomfortable in that situation.

eN6

The eTHOS nurses also made a number of practical recommendations regarding changes that could be made to the study design, for example, database flow, process for signing off normal blood results details of which have been collated and filed for future reference.

Acceptability of concept

The providers were, to varying degrees, supportive of the concept but it was recognised that its effectiveness would be limited by the extent to which staff engaged with it. But it was seen as a positive starting point: ‘Starts the conversation about lifestyle, and the majority of … staff … I see … are deconditioned’ (PT3).

It was pointed out that the intervention’s impact would depend on what exactly providers could offer: ‘So what I would say is there’s massive benefits if the screen tool is picking things up, that is then the availability of the services to provide that’ (PT2).

The need for physiotherapy with CBT is an example of potential issues around availability as not every site could offer such a service and where it was available, the capacity for referrals was limited. Limitations were also reported in relation to infrastructure, with gyms having been reassigned as ward space due the pandemic and with no imminent plans to restore them to their original use.

There was also concern about the intervention’s limitations. Although the physiotherapy departments had an in-house self-referral system for staff, the physiotherapists reported that they did not feel that there had been any extra service provision to support it.

As I said occ health, just seems, the referrals we get seems to grow and grow anyway without really any extra staff, and I think, I’m sure as everywhere in the NHS, we’re just being asked to do more with less people all the time.

PT1

In relation to organisational culture, one physiotherapist talked about the benefits of creating an environment where staff left the ward, ideally for a walk, for at least 15 minutes during their working day. This physiotherapist also viewed exercise prescriptions as being just as important as physiotherapy. In addition, it was pointed out that other organisations have dedicated physios for their staff.

Finally, there have been negative experiences in primary care of non-NHS screening programmes which have brought up ‘[i]ncidentalomas’ (GP1).

The GP explained that alarmed patients had presented with findings from private screening programmes such as a raised prostate-specific antigen (PSA) test or osteoarthritis which the GPs then had difficulty explaining to the patients as being not clinically relevant. This echoed concerns also expressed by participants.

Impact on service

Each of the physiotherapy departments represented had self-referral systems in place for staff. Trial participants requiring physiotherapy accessed treatment using this system, that is, using the same referral route as staff not involved in the study. Therefore, the physiotherapists had no way of identifying which members of staff had been referred as a result of eTHOS’s screening process. However, neither reported any noticeable increase in referral rates. This is useful as one of the physio departments had previously expressed concern that they would not have capacity for any additional staff referrals and had suggested that referrals should be picked up by another site within the Trust.

We identified that the impact on GPs would vary depending on how many practices there were serving the local site, the size of such practices and the extent to which staff lived locally or commuted from surrounding areas. Another important factor was whether or not the hospital sites offered in-house or subcontracted services such as physiotherapy or mental health support. Therefore, the impacts would be greater on large practices in small communities where staff tended to live locally and the site had no in-house services.

The GP interviewed was from a practice that served a number of the interviewed trial participants. They had only become aware of the study because of confusion over a referral arising from eTHOS. None of the staff in the practice had remarked on an increase in referral rates from eTHOS or staff at the local hospital.

Referral pathways

A challenge faced by both eTHOS nurses and GPs was that local services for weight management and smoking cessation change over time. Services, if available, are commissioned by the local authority that frequently contract the delivery and management to outside agencies. This means that providers change according to who has won the contract in the most recent round of bids. Other services (e.g. some slimming groups) are entirely private and may not have any links with statutory authorities; they may change time and location of sessions depending on availability of local representatives to run them. These factors were all compounded by the COVID-19 pandemic and staff not knowing what services were running within the current constraints, constraints which themselves were frequently changing:

We have … no access to dietician support for weight management locally … there are other referral pathways … like the health lifestyle trainers, which is through [names local leisure centre] which is the local council run gym, swimming pool etc., there has been historically. I don’t know how active it’s now, certainly back then, years ago, it was a very popular option, but I have heard very little, and whether that’s because things shutdown over COVID and haven’t got going again, or whether it’s just not been as well promoted recently I don’t know.

GP1

In addition, one of the sites was unaware that the in-house physiotherapy referral process had changed. During the physio interviews, we discovered that each site seemed to have a physiotherapist dedicated to staff referral. If the intervention went to full trial, actively involving these physiotherapists in setup would improve lines of communication between the staff delivering the intervention and the physiotherapy department.

Acceptability of concept

Outside agency respondents tended to report feeling that health screening would be a positive step to take that tackled absenteeism:

I thought the tool was good, and it’s much better than what happens with nurses at the minute, which is really just crisis management, once they go off sick then there’s some sort effort made to try and deal with it.

OA3

The health and well-being of staff were recognised as important to service quality in industries as diverse as health care and manufacturing:

If we don’t have a workforce that is healthy coming to work and are in a good place to do their work then none of the other stuff happens. So yes I think it’s hugely important. It’s a key direction of travel for us as a team … if we don’t get that bit right then the rest of it suffers.

OA10

The intervention was perceived to be particularly important in light of the pandemic:

I think with what’s going on in the world right now people need as many interventions as possible, and I think people overlook their general health, their musculoskeletal issues because they are dealing with dodging COVID or dealing with grief or stress. So I think it’s a fantastic idea.

OA11

Health screening was seen as an innovation to more traditional approaches to staff well-being, often characterised as ‘firefighting’:

We know that if we put more money into prevention we would spend less overall, as in do you know what I mean? But it’s a chicken and egg situation where we would describe ourselves I used the term this week we’re firefighting again at the moment.

OA9

Despite support for the screening intervention, screening was also perceived by some to place too much emphasis on the individual employee to enact change, when they may be powerless to establish a responsibility for workplace environmental adaptations or cultural change; something seen as a key causal mechanism of mental and physical health decline:

I believe that part of the mental health issues that nurses suffer in a hospital environment is due to the way that they are managed, but I thought the tools reflected that all of these issues were intrinsic rather than some of them being extrinsic … it felt a little bit like it was blaming the nurse for the position that they have got in, whereas the reality is that the nurses quite often will say there’s job pressure, there’s time pressures, but I am not always respected or treated very well, I feel that I have to work without supervision or above the level that I feel competent. But that wasn’t really reflected in the process … it seemed like somebody would present with a problem and the tool said to them it’s your problem, go away and sort it out, we’ll give you some help. It didn’t feel like there was that top down view where it says maybe we are causing part of that problem, what can we do to prevent it in the first place, rather than dealing with it once it manifested itself.

OA3

Referral pathways were also problematised. Instead of the onus being on GPs, it was felt internal NHS services should be accessible: ‘It really should flag straight to in-house, if hospitals have in-house referrals for physiotherapy or in-house counselling services rather than it being sent to a GP and GP then saying please can you sort this out’ (OA13).

Feasibility of intervention delivery

Widespread, strong interest was reported in trial participation by outside agency respondents with respondents making offers to obtain support from key stakeholders:

Practice wise I would just need to run it past the practice manager, get her to be happy … if you want me to do that I am happy to. CCG wise I would have to take it to the chief exec of the CCG and probably HR, again happy to do that.

OA13

One outside agency offered data for comparison in way of support for the study:

One of the things that I might note is that whilst we might not be that useful for the trial, we do gather a lot of data about this sort of stuff … it might be that we can offer some useful contrasts or some comparisons, so we might add some value there where if you ask us for metrics we could perhaps give you equivalence from the private sector.

OA3

The vaccination roll-out was perceived to have demonstrated the feasibility of delivering healthcare provision on site at some outside agencies. One organisation was keen to build upon the momentum of the vaccine programme, feeling eTHOS represented a good opportunity to be ‘the next something’:

We have shown that we can put 4000 through a programme in a day, we can do some amazing things, so we know we can do it if we get the design right and if we hit that sweet spot the business is willing to release them from the line … we have a lot of goodwill with our trade union colleagues, they want to work with us, so we have got an engaged trade union and workforce ready to do something, we just need to present them with the next something, and I think we’ll get good engagement on that.

OA8

Challenges to trial success were reported to be largely practical, that is having to travel for screening appointments due to not being on site, or ensuring the study is visible to staff when they are rarely in a work building. This was particularly the case for agencies where staff perform a lot of remote working, such as community nursing and paramedics:

They [staff] don’t spend huge amounts of time on the hub. So we have got ways of dealing with that, but that is definitely a challenge, because we are not highly visible because they are not there if that makes sense?

OA10

People then have to travel because it’s not actually going to be based at their own base. So that then, so the model needs to be thought through in a dispersed organisation geographically, because face to face works really well in the big sites so that you could go to the dental hospital, you could go to [hospital], you could go to [hospital], there’s staff here at headquarters, there are a number of big sites, but there are lots of teams who have got the same needs who are based in very small health centres, and some of them may prefer this type of engagement.

OA1

The primary barrier was funding nurse time to deliver the intervention. Those employing clinical staff did not have capacity to run a trial without such funding:

We do have nurses doing occupational health work. The challenge is they are flat-out. I think what we learnt from some of these initiatives that we have already run is we can provide the facilities, we can provide the patient, what we really struggled to deliver was the actual clinicians.

OA8

Participants working in the provision of occupational health were concerned about short-term increases in demand for their services due to manager concerns around staff health and contamination:

Managers will become aware of something they weren’t before, and then might go right I need to know the advice, yes I am sure they are doing this research screening programme but I need to know how I manage them now, what are the impacts for how they are working. The only other thing is the expectation staff … who hear about it later will go, ‘I wish I had known about that, I will speak to occupational health, I will see what they are doing now.’

OA9

We explored with the one interviewed GP whether or not they would be interested in delivering the screening tool to NHS staff either as part of a RCT or as a funded service. The GP felt that their practice would be unlikely to have capacity for either, regardless of funding.

Key findings

Comparison with existing literature

While current smoking rates in our staff participants were slightly lower than other studies (8% vs. 10–12%),17,18 many more were overweight or obese – 69% compared with just over half found in other surveys of NHS staff. 17,18 Sixty-nine per cent were active or moderately active; this compares reasonably with the Public Health England data. 76 Sixteen per cent and 17% reported current symptoms of anxiety and depression with the screening tools, reflecting the impact of the COVID-19 pandemic observed in other published studies. 77 Just under 40% of those eligible reported ever having received an NHS health check, which is a little lower than the national average of 43.8% in 2019–20. 78

Our participants reported being absent for a mean of 10.5 days in the previous 12 months, although the HR records indicated this was higher at 13.2 days, more than previously reported literature and therefore reflecting increased rates during the pandemic. 79

Recruitment rates to our trial were less than expected, with 8% of those invited consenting to take part (6% finally randomised). These were lower than comparable studies pre pandemic,56 and may be reflective of the pressures of healthcare staff during the pandemic. However, it is well established that recruitment to trials of healthy adults is generally lower than that of participants with particular diseases and therefore our projections were probably optimistic. Consistent with other studies, recruitment rates were generally lower among those of minority ethnic groups, lower paid staff and those working nightshifts, a feature which requires addressing in a future full trial, but which should be easier post pandemic as more face-to-face opportunities will arise for recruitment.

Among those randomised to the screening intervention, there was a high need (i.e. those eligible) for onward referrals (48.3%), particularly to the GP (38.9%) and physiotherapist (14.4%). These are conservative figures as 14% of those randomised did not receive the intervention. Provisional acceptance of referrals was around one-third of those eligible.

Strengths and limitations

A major strength of our trial was the use of electronic data capture throughout the recruitment process, intervention delivery and outcome data collection. While more complex to develop, it minimised the need for face-to-face contact during the pandemic, reducing staff pressures for delivery and data entry and minimising risk of infection. Most participants entered the study directly through the trial website after receiving an e-mail from Trust systems. The electronic system also allowed for flexibility, as staff could participate during or outside work hours, and/or on their own devices if they wished. It is possible that a few staff would have been excluded from participating if we had not also had the option to complete consent and baseline data collection at the screening clinic, and optimisation of this method of recruitment needs to be considered for the full trial to ensure underserved groups with less access to Trust e-mails have the opportunity to participate.

Our electronically driven intervention also promoted high fidelity to the assessments and processes within the protocol, although some viewed this as being impersonal and lacking flexibility at times when there was clinical need. Despite the prompts, eTHOS nurses did not always feel it appropriate to state that they had referred (e.g. when they had encouraged self-referral), leading to some potential misclassification. Questionnaires were quite long, but they were thought to be largely manageable and completed well and used standard self-report questionnaire instruments.

While most people were prompted to join the trial via their work e-mail, our multifaceted trial promotion strategy improved recruitment as some were prompted through the posters, postal invitations and by word of mouth. Unfortunately, we found that recruitment was less successful within ethnic minority groups and lower paid workers, and this may have led to response bias affecting the assessment of health need or referrals required. Many of the face-to-face opportunities planned to promote the trial (daily briefings and staff rooms) were unavailable during the pandemic which may have impacted both on overall recruitment and participant demography. Our phased approach to sampling allowed us to invite participants in a way which was representative of the hospital population, but further work needs to be done to optimise engagement in those groups.

Because of the pressures of the pandemic, we were delayed in starting the trial, and therefore the majority of the recruitment and intervention delivery was compressed into a 6-month period, allowing little room for reflection and adaptation of methods. Despite this, recruitment was rapid and a large pool of available staff and flexible deployment of our phased plan meant that we could recruit two-thirds of our target in only 3 months. The time constraints and reduced availability of service staff and space available meant that both internal and external referrals to physiotherapy and mental health services, in particular, were more limited; smoking cessation and weight management services were already disrupted and GPs under pressure. As a consequence, referral pathways were not always clear. This situation is already improving and we will be able to recruit sites with good pathways in place for the full trial.

Due to early closure of the trial in response to the pandemic and funder timelines, we were unable to complete our planned follow-up in all participants and unable to fulfil the planned number of qualitative interviews, although the data retrieved were rich. Time frames and sampling for the interviews were suboptimal, and although broadly generalisable of trial participants, included more nurses than other groups. Limited follow-up also precluded assessment of some secondary outcomes including definitive trial effectiveness outcomes and likely data completeness. The final process of generation of referral letters could not be automated in the time frame but this will be addressed in future iterations of the database.

Aside from the practical problems, the COVID-19 pandemic completely altered the health, health service and research context. It is not clear how recruitment and clinical need might have been impacted; the pandemic raised the profile and culture of research amongst the healthcare staff population, but conversely may have contributed to research fatigue. The results of this feasibility study may not be fully generalisable to non-pandemic times but gives a good indicator about what can be achieved even under enormous pressure.

Generalisability

We conducted this feasibility trial in four different hospitals, but three were large teaching hospitals in central Birmingham, two of which were part of the same Trust. One of these (QEHB) had already run a similar pilot clinic and therefore there will be some lack of generalisability; performance of new Trusts in a larger trial might differ. However, the small rural hospital outperformed their recruitment targets and delivered the intervention similarly to the large urban hospitals.

Implications for research

Implications for practice

Enhancing the Health of NHS Staff was a feasibility trial and therefore there are no direct implications for practice until the full trial has been conducted. However, there are a number of observations which can be drawn from the data and the experience gained through this pilot.

First, that the health of NHS staff warrants attention, with nationally validated/supported screening tools identifying a high burden of previously undiagnosed poor health. Without intervention, this could have significant impact for the future NHS workforce, and therefore patient care.

Second, that NHS staff welcomed and valued the staff screening clinic. Although staff highlighted that the clinic could not address all of their concerns or the workplace challenges or cultures which might be exacerbating ill health, most agreed that the clinic focused on important aspects of ill health.

Third, it is possible to deliver a staff health clinic even within highly challenging clinical environments, such as during waves of a pandemic. This supports the deliverability of the clinic across diverse healthcare settings in more normal times.

Fourth, this trial had widespread support from NHS Trusts at executive board level, enabling its delivery when the NHS was faced with competing priorities and highlighting the value health organisations placed on our endeavour to improve NHS staff health. All three Trusts have asked to be part of the definitive study and others have expressed a strong interest. This also highlights the likelihood that a definitive study would be supported by national healthcare organisations and that any effective services adopted nationally.

Fifth, for the staff health clinic to be most effective, there must be clearly identified pathways for onward referrals, within a reasonable time frame. During the COVID-19 pandemic, there was a disconnect to community services such as counselling, physiotherapy, smoking cessation and weight management, although this situation is now improving. Rapid access to in-house services outside of our trial could potentially be considered by hospitals to address the clear needs identified within their staff population, supplemented by close relationships with community provision. A centrally funded service could potentially have a number of models, including a hub and spoke from larger hospitals.