Don’t sleep on it!

Excessive daytime sleepiness (EDS) is the main focus of DVLA concern with people diagnosed with Obstructive Sleep Apnoea (OSA), a condition in which sufferers experience significant periods of not breathing, while they are asleep during to airway obstruction.  Inadequate oxygenation of the body from OSA is bad for general health.  Lack of deep sleep leads to those affected being fatigued and falling asleep easily during the day (even if they are not aware of OSA). Drivers who suffer from Sleep Apnoea must notify DVLA to get their condition reviewed and controlled before they can go on driving. DVLA are solely concerned about falling asleep while driving, not other health issues including exacerbation of diabetes or the increased tendency to heart disease and/or stroke.

Some reports suggest that about 20 per cent of adults suffer a significant degree of EDS, although OSA is only one cause. A far bigger cause is disturbed sleep due to things like shift work and caring duties for infants and sick dependants involving waking nights.

ESS (Epworth Sleepiness Scale) and AHI (Apnoea Hypopnoea Index) scores are used by medical practitioners to assess tendency to EDS.  Some research suggests that ESS results are subjective and sleep specialists warn against them as wholly reliable assessments of EDS. Other research suggests that there is no clear correlation between AHI and ESS scores.

In assessing the risk of sleepiness while driving, AHI is a not very reliable measure for tendency to EDS.  Arguably, were a better tool available and widely adopted, the DVLA might reduce its fixation on OSA. Many more ‘at risk’ drivers might be brought into the DVLA medical surveillance net, while at the same time releasing from continuing medical surveillance some OSA suffers who do not suffer significant EDS. Sleepiness, however, is a very transient and subjective state for which there are few reliable markers.

Medical practitioners should be made more aware of other non OSA related causes of EDS and arguably, where these cannot be brought under satisfactory control, DVLA should be informed as they are in cases where significant OSA is diagnosed.

At present the duty to inform DVLA about OSA is triggered by medical diagnosis. Opinions and guidance vary as to whether, once diagnosed, the OSA suffer should cease driving until given permission to resume by DVLA. DVLA stress that the primary duty not to drive while unfit from any cause rests with the driver. More publicity about sleep and driving may cause some drivers not to go to their doctors for fear of being suspended from driving while awaiting treatment – but in practice this fear is unfounded. Treatment, such as using CPAP (continuous positive airway pressure) equipment at night is available via NHS sleep clinics and with a bit of practice is quite easy to use. It can quickly help the OSA sufferer to feel a whole lot better and have a lot more energy. More guidance is still needed for employers and potential sufferers.  Responsible drivers need to pay more attention to ‘sleep hygiene’ and to finding ways of remaining alert when at the wheel. They need to be prepared to discuss sleepiness issues with their doctors and not be afraid of being caught in the DVLA medical surveillance net.

Sleepiness and road safety have been a big part of RoSPA’s policy and campaigning work on managing Occupational Road Riskcampaigns for nearly twenty years. (See our advice to employers at https://www.rospa.com/road-safety/resources/free/employers.) The key message is that employers must not cause their drivers to drive tired. It needs an intelligent approach. Anyone who feels sleepy at the wheel, regardless of the cause, knows they are becoming impaired and must stop and recover until they are safe to proceed.

RoSPA’sNational Occupational Health Safety Committee (which brings together the main institutional stakeholders in this area) has begun work on tackling fatigue in the workplace. This is not only highly topical because of its links to mental health and ‘wellness’ but its impact on safety and accidents in the workplace have generally been underplayed up to now. New guidance however is now available in the form of the HSE fatigue risk index (see http://www.hse.gov.uk/research/rrhtm/rr446.htm).

ROSPA are thinking about producing some guidance on OSA and Employment (‘OSA and your job’ perhaps?), helping both sufferers and their managers to better understand the issues involved and to avoid over-the-top, excessively risk averse responses that might lead them to exclude OSA sufferers from certain roles ‘on health safety grounds’. Talking to specialists and consultants reveals how reluctant many of their patients are to reveal to their employers that they have had an OSA diagnosis.   There is undoubtedly a lot of prejudice and misinformation in the workplace about this issue, and about fatigue and sleepiness generally – which, of course, goes a lot wider than OSA. ‘cat napping’, as an essential coping mechanism in the workplace, (especially for older workers who make up a bigger proportion of the workforce these days) ought to be a widely understood and accepted coping mechanism, not seen as an outlandish idea.

If you have experience in tackling problems experienced by workers in getting enough good quality sleep we’d like to hear from you.

Roger Bibbings MBE CFIOSH

Partnership Consultant RoSPA                                             May 2019

Do Fit notes always Fit the Problem?

Minister Matt Hancock recently launched the NHS Long Term Plan that highlighted our need to address the high rates of employment sickness absence due to musculoskeltal (MSK) problems and/or mental ill health.

Let’s look at some stats: 9 to 10 million GP Fit Notes are signed annuallyin England alone. A colossal number, likely to be taking an inordinate amount of precious GP time, particularly when 80% of these are used by employees as evidence of their illness for their employer as required by HR policies. 93% of GP Fit notes say that the person is not fit for work. Surely it’s time for another approach that chimes with the upcoming changes in GP Surgeries?

Work related problems are mainly identified in GP surgeries which are already taking the strain of high patient demand with a shrinking workforce. So it is great news that the NHS Long Term Plan sets out to expand the multi disciplinary team (MDT) workforce in GP surgeries to help meet demand. Ambitious pilots using allied health professionals (AHPs) like occupational therapists, paramedics and physiotherapists have shown safe, cost effective results that patients and families welcome. Seeing an AHP as a First Contact Practitioner from your GP surgery is going to become more the norm.

Which leads me back to my question….do Fit Notes always fit the problem? So, if you were off work, would you use a confidential work clinic based in your GP surgery? You may be surprised to learn that a growing number of patients are doing just this and using newly opened clinics in Southampton and South Pembrokeshire. Occupational Therapy Led Vocational Clinics are for people who are in employment and struggling with MSK and/or mental health problems. A safe space where they can talk through what work difficulties they face and how these may be resolved. Everybody gets an AHP Health and Work Report which can be shared with the employer with advice about how work modifications could keep the person in work.

• Does the patient get individualised work and symptom management advice? Yes
• Does the employer get more detailed, accurate info about how to support staff? Yes
• Can the employer use the AHP Health and Work Report as evidence for statutory sick pay? Yes.
• Does it cut down on GP time writing GP fit notes? Yes but …

…..to embed this new approach, we need employers to understand that there are alternatives to the traditional GP Fit Note. If they and the employee want to use alternative evidence than the GP fit note, this is available now and the legislation allows it.

So the question for employers may be ….would you prefer a detailed report saying how someone can stay at work by an AHP or a GP fit note just saying they are not fit for work? The answer will depend on the clinical situation of course, but the AHP Health and Work Report can provide the clear instructions that employers often crave.

Full results of the Occupational Therapy Led Vocational Clinics will be available in March 2020. These Clinics are one of 19 initiatives across the UK selected to receive funding from the Work and Health Challenge Fund.

#OTVoc.

#WHChallengeFund

Genevieve Smyth

Professional Adviser

Royal College of Occupational Therapists

Hans Pung is the President of Rand Europe. Marco Hafner is a senior economist at RAND Europe

Having the motivation to keep exercising regularly can be challenging for many of us. The benefits of regular physical activity are widely recognised yet about one third of the world’s adult population is not meeting the minimum weekly level of physical activity as recommended by the World Health Organisation. Weekly exercise can result in a lower risk of some diseases such as cardiovascular disease, diabetes and cancer, as well as maintain a healthy body weight and mental health. So the question is: what will motivate people to keepheading out the door, whether it’s for a swim or to the gym, for some much-needed activity?

Existing evidence suggests that incentive programmes can have a positive impact on people’s healthy behaviours, and in particular on physical activity, but the type of incentive matters. A recent RAND Europe report has highlighted the impact a particular “loss-framed” financial incentive scheme has had on people’s activity levels. Think of a loss-framed incentive as more of the proverbial “stick,” as opposed to the alternative gain-framed method or “carrot” reward for healthy behaviour. The stick in our study being people having to pay higher or lower monthly amounts for a smartwatch, depending on how physically active they were.

In the study researchers reviewed the data of more than 400,000 people, across the US, UK and South Africa, who had signed up to the Vitality Active Rewards programme run by multi-national health insurer Discovery. Members were rewarded for healthy behaviour with “Vitality points” which they could then use towards benefits – the carrot – such as movie tickets or free hot drinks. Members on the Vitality Active Rewards programme could also take up the Apple Watch benefit. This allowed members to buy the smartwatch and fitness tracker at a discounted price. Monthly repayments would then vary according to their level of activity during the previous month. If people exercised regularly and tracked their activity to earn enough points they would not have to pay any further costs.

Analysis of the data showed that those people who took up the Vitality Active Rewards with Apple Watch benefit increased their physical activity by about 34 per cent per month, compared to those who only participated in the Vitality Activity Rewards points programme. This meant that on average, people were exercising nearly five days extra every month. Also, the type of activity was recorded as advanced, meaning that not only did people exercise more while on the programme, they also exercised more intensely.

Notably, the study also looked at whether the increased physical activity levels persisted over time. Members on the Apple Watch scheme had two years to pay off the watch and researchers found that the levels of raised activity were sustained throughout the 24 month period. So it would suggest that people needed the extra push from a loss-framed incentive to stay motivated and maintain a positive behaviour change, over and above the rewards offered on the Vitality Activity Rewards points scheme. Offering members the opportunity to update their smartwatch every two years and continue the repayment process may also help them to stay active.

Previous studies contributing to this area of research have been done before, but never on so large a scale. Neither have they covered such a wide subject area. People who took part in the scheme varied widely in their fitness levels and the RAND Europe study showed that the benefit also incentivised those that initially tended to be more inactive, such as obese individuals, to become more active. Granted, fewer people in this at-risk group took up the benefit, however for those that did, they also showed a significant increase in activity levels.

While by no means a magic bullet, the combination of modern technology and the loss-framed incentive would seem to make a significant impact on people’s motivation, helping them to huff and puff their way to the desired amount of activity every week. This effect is important to consider when designing fitness and wellbeing programmes, whether it be for a health insurance company, employer or local GP. Finding ways to encourage healthy behaviour is vital and this might be the type of motivation people need to make it a way of life.

Hans Pung is the President of Rand Europe. Marco Hafner is a senior economist at RAND Europe and lead author on the “Incentives and physical activity” study.