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Occupational Medicine 2007 57(2):145-148; doi:10.1093/occmed/kql143
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C. S. Mutalik, Ministry of Defence (Army). © Crown Copyright 2007. Reproduced with the permission of the Controller of Her Majesty's Stationery Office.

Short Reports

Training interventions for general practitioners providing an occupational health service in the British Army

Chandrakant S. Mutalik

MOD (Army)—HQ APHCS Eastern Region, Ypres Road, Colchester, Essex CO2 7NL, UK

Correspondence to: Chandrakant S. Mutalik, MOD (Army)—HQ APHCS Eastern Region, Ypres Road, Colchester, Essex CO2 7NL, UK. Tel: +44 7786 511652; fax: +44 1206 783616; e-mail: mutalik{at}btinternet.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background General practitioners (GPs) working in the British Army, whether civilian or military, are responsible for providing a first line occupational health (OH) service in addition to their primary health care role. Despite the medical classification system being well established, previous publications have shown considerable inconsistency in the knowledge among GPs.

Aim The aim of this audit cycle was to test effectiveness of training interventions designed for GPs, providing the first line OH service.

Method The audit cycle was divided into three stages. The Stages I and III were audits examining the standard of OH records initiated by GPs during a 4-month period (pre- and post-training). The Stage II was a training intervention. Statistical significance was assessed with the chi-square test.

Results The stage one audit showed a statistically significant standard difference between the medical boards initiated by civilian and military GPs. This gap was bridged and the overall standard of the OH records improved significantly after the training.

Conclusions Appropriate training can enhance a first line OH service provided by GPs. The training must be reinforced at regular intervals. Both OH specialists and GPs can complement each other so as to identify, intervene and prevent work-related ill-health.

Keywords      Army occupational health; audit; GP training; PULHHEEMS system


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
The British Army uses the PULHHEEMS system, which is an essential element of the occupational health (OH) service. The acronym PULHHEEMS stands for P, physical capacity; U, upper limbs; L, locomotion (legs and spines); HH, hearing standards (right and left); EE, visual acuity (right and left); M, mental capacity and S, stability. It is described in full in a Joint Service Publication (JSP) 346 [1] and the PULHHEEMS Administrative Pamphlet (PAP) 2000 [2]. General practitioners (GPs) working in the British Army, whether civilian or military, are responsible for providing a first line OH service. As OH providers, they are responsible for initiating medical boards which allocate an appropriate employment category.

Despite the classification system being well established, previous publications [3–5] have shown considerable inconsistency in the knowledge among GPs.

The aim of this audit cycle was to test effectiveness of training interventions designed for GPs, providing the first line OH service.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
The audit was carried out in the Army Primary Health Care Services (APHCS) Home Counties (HC) Region involving 16 medical centres. APHCS employ both military and civilian GPs. The OH team comprised an occupational medicine (OM) consultant, a specialist registrar and a specialist nurse. The audit cycle was divided into three stages.

Stages I and III were an audit cycle examining the standard of all OH records (medical board documents) initiated by GPs during a 4-month period (pre- and post-training). The documents were collated and evaluated by the OH team against pre-defined criteria as stated below. The criteria and their evaluation were based on the policy documents, JSP 346 [1] and PAP 2000 [2]. A pilot study was carried out beforehand to confirm its reproducibility. Statistical significance was assessed with the chi-square test and data accepted as being statistically significant if P < 0.05.

Predefined criteria

(i) Were policy documents followed in the medical board?
(ii) Were the individual's administrative details complete?
(iii) Were the given clinical details complete as instructed in PAP 2000?
(iv) Was height–colour perception–weight recorded?
(v) Was the patient given an opportunity to ask questions? The PAP 2000 directs that this information should be recorded in the medical board document.
(vi) Were the awarded medical grade and employment category appropriate?

Stage II consisted of a training intervention, which comprised a PowerPoint® presentation and a reading pack giving a brief outline of the system and medical boarding procedure. It was designed after consulting the OM consultant advisor for the Army. The training was aimed at GPs and learning outcomes were to enhance the overall standard of OH records. The region's OH team delivered this training over a 6-month period.

Besides this training, supplementary guidance was offered in the form of the OM physician doing some medical boards with the GPs and demonstrating to them the standard method for completing the OH records.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
The PowerPoint® presentation was delivered to 40 (79%) of GPs but attempts to cover those remaining were unsuccessful. The reading pack was received by all. The table shows the results of the audit cycle and a comparison between standards of the OH records initiated before and after the training. The stage one audit showed a statistically significant standard difference between the medical boards initiated by civilian and military GPs. This gap was bridged and the overall standard of the OH records improved significantly after the training.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
The results of the stage one audit suggested a lack of compliance of GPs, especially the civilian GPs, with the medical board process. It was felt that a lack of training in the PULHHEEMS system was the key reason behind this outcome. The results of this audit cycle clearly indicate a statistically significant improvement in the standard of medical boards initiated post-training.

Although the method was tested for its reproducibility, it may not be possible to completely eliminate bias while assessing the criteria. The policy documents give comprehensive guidance on this subject thereby reducing the bias.

A previous audit has reported that only 46% of GPs had received formal training [3]. Military MOs receive some training during their Entry Officer Course but there is no arrangement to reinforce it further. An OH report should be impartial and hence, GPs may be finding their role as OH providers conflicting with their primary care role.

It is essential to document comprehensive clinical details in OH records. A previous study of similar documents reported a significant deficit of clinical details in 44% cases [4]. As indicated in the Table 1, some records had insufficient clinical details to apply the classification system and to decide on suitability of employment grades. The training improved the degree of clinical details, subsequently facilitating an appropriate advice on individual's employability.


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  		Table 1. Results of the audit cycle

 
It is difficult to quantify the overall impact on the organization but as a result of this audit and intervention all GPs received some formal training and more employees were placed in the correct employment grade. The employer has a duty of care to reduce risk and provide a safe working environment. The correct employment grading is expected to reduce the risk of injury/illness and future litigation. Furthermore, line managers will be able to make reasonable adjustments at work, applying principles covered under the Disability Discrimination Act.

The audit highlighted the benefits of training interventions. This training should be revised at regular intervals to maintain knowledge and skills. A recent publication ‘The Health and Work Handbook’ encourages primary care and OH teams to work together [6]. With effective training, GPs can provide a first line OH service and the OH specialist can run a secondary level consultancy.

In conclusion, appropriate training can enhance a first line OH service provided by GPs. OH specialists and GPs can complement each other so as to identify, intervene and prevent work-related ill-health.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
The author thanks Colonel M. G. Braithwaite OBE and Colonel R. Thornton for supervision and guidance and the medical staff at medical centres in the APHCS HC Region.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. Joint Services Publication 346. (2003) PULHHEEMS—A Joint Service System of Medical Classifications, D/SG(MEDPOL)/320/2(Ministry of Defence, London).

  2. Ministry of Defence. Army code 13371. PULHHEEMS Administrative Pamphlet 2000, D/DM(A)/82/32/D/STOS (2000) (Ministry of Defence, London).

  3. Adams MS. (1998) Fitness for work: an audit of the British Army Medical Classification System. Dissertation for Membership of the Faculty of Occupational Medicine. (Royal College of Physicians, London).

  4. Wright LJ and Owen JP. (2002) An audit of Territorial Army medical grades on presentation for mobilisation and full time reserve service at RTMC Chilwell. J R Army Med Corps 148:262–265.[Medline]

  5. Hodgetts TJ and Greasley LA. (2003) Impact of deployment of personnel with chronic conditions to forward areas. J R Army Med Corps 149:277–283.[Medline]

  6. Gunnyeon B, Parker G, Sharp C. (2005) The Health and Work Handbook(Faculty of Occupational Medicine, Department of Works and Pensions and Society of Occupational Medicine, London) (https://www.som.org.uk/fileadmin/pdf/HandWhandbk.pdf).


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This Article
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