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For London Ambulance Service, Student Paramedic Course

Can the LAS deliver health promotion? – Leading by example

In November 2010 the NHS launched “self care week” across London (15-21st November 2010). Its aim was to help Londoners understand how to take medicines, treat minor ailments and to give them the tools to stay fit and healthy (NHS 2010). Steve Lennox Director of Health promotion for the LAS said “learning to look after your health is a good thing. It puts you in control, improves your quality of life and helps you live more healthily” (NHS, 2010).

The Ottawa Charter for Health Promotion (WHO 1986) stated that “the role of the health care sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services” and its aim was to “achieve health for all by 2000 and beyond”.

Whilst the most recent figures from the ONS (Office of National Statistics) show a trend of increased life expectancy, from 76 to 78 years between 2001 and 2008 for males and an increase of 80.7 to 82.1 for females accompanied by an increase in healthy life expectancy (ONS 2006 & ONS 2010), this may be a trend that is about to change. With the media suggesting that the current generation may be the first to outlive there children the WHO (World Health Organisation) warned in 2005 that an estimated one billion people are overweight and that the figure is estimated to rise to 1.5 Billion by 2015 (WHO 2005). In the same report Dr Robert Beaglehorn stated that “approximately 80% of Heart Disease, Stroke, and Type II Diabetes and 40% of cancer could be avoided through healthy diet, regular physical activity and avoidance of tobacco use”. This highlights that the aims of the NHS ‘Selfcare’ initiative are increasingly relevant. Whilst the health of the nation is the primary concern the benefits of health promotion are not merely physical. The increasing burden of poor lifestyle choices is currently estimated at costing the NHS some £4.2 Billion per year as well as the wider burden to the economy of a staggering £16 Billion per year (Department of Health 2010) and an estimated 18 million sick days annually (Comptroller & Auditor General, 2001). Moreover as the population ages, the number of people with a long standing illness or condition is expected to rise (Mooney 2009).

The ‘Selfcare’ page on the NHS website provides information on; weight-loss, getting fit, stopping smoking, cutting down on alcohol and eating more healthily (NHS 2010). The LAS (London Ambulance Service) supported this initiative, advertising it on its website and Chief Executive Peter Bradley reiterated his commitment to health promotion in his response to a government white paper this year stating that “ the Service increasingly sees public health promotion as being one of its key roles” (Bradley 2010).

It is clear then that Health Promotion is to become a fundamental and integral part of the future of the LAS and that road staff will be increasingly encourage to promote services and initiatives relating to good health.

The obvious way in which the LAS can contribute is to try to educate and influence some of the 1.2 million callers that telephone the LAS annually, but how can our staff lead patients to a healthier lifestyle?

According to the American motivational coach John C Maxwell “A leader is one who knows the way, goes the way, and shows the way.” (Maxwell 2001), so are NHS and LAS staff fit to lead the way?

As one of the largest employers in Europe the NHS employs 1.43 million members of staff (NHS 2009) representing a considerable proportion of the total UK population. If the NHS could mobilise its entire personnel to improve there own health they could be empowered as champions of health promotion both at work and in their personal lives with the potential to change the habits and health of the nation.

The LAS employs over 5000 staff (LAS 2010) and have contact with over 974,000 patients a year (LAS 2009). It is apparent from personal experience that habits on the road for the most part are far from healthy; I am a former semi-professional athlete, qualified Sports Scientist and Personal Trainer so I feel qualified to comment. This is perhaps backed up by the sickness record of LAS personnel. To put things in perspective the national average of sickness related absence from work was 5.8 Million days representing 1.5% of total available working time (leaker, D. 2008), where as the NHS figures are an average of 3.89% with the worst NHS work force being ambulance personnel at 5.91% (Bullard, I. 2010) making ambulance staff almost four times more likely to be absent from work for health related matters than the average worker.

So why are ambulance personnel apparently so unhealthy? It was reported that most ambulance staff are exposed to acute stressors at work and that many reported more chronic work related stressors compared with a reference group. The same study reports that more than 10% suffered from clinical levels of post traumatic distress, 10% reported fatigue levels placing them at high risk of sick leave and 10% suffered complete burnout (Ploeg & Kleber 2003). Another study suggests that “The mental health and emotional well-being of ambulance personnel appear to be compromised by accident and emergency work” (Alexander & Klein 2001) making mental health and stress a key factor in absence. Secondly back injury appears to be a major factor according to Mark Gough the Deputy Clinical Governance Manager of the West Midlands Ambulance Service ambulance staff are “seven times more likely to be back injured than in any other occupational group and they usually have to retire before their time” (Gough 2000).

It is easy to look at this information and to focus on initiatives that relate directly to mental health within the work force such as coping strategies and in back injury prevention through equipment and education. It is perhaps overlooked that general fitness levels can have a huge impact on both these factors and to the wider health and wellbeing of road staff.

Individuals who participate in regular exercise program that incorporates back and core conditioning programs significantly protect their backs from injury at work (Maher, C. 2000) and a literature review found that 32% of low back pain and back injuries could be attributed to being overweight in the first place (Leboeuf-Yde & Charlotte 2000). In separate studies exercise was shown to improve metal health, researchers at Duke University studied people suffering from depression and found that 60% of the participants who exercised for 30 minutes three times a week overcame their depression without using antidepressant medication, interestingly the same success rate reported by taking medication (Panning 2000).

Research into the health and fitness of ambulance personnel suggests that 52% could be classified as overweight and 10% obese and that 54% of over 40 year olds and 24% of under 40 year olds in service found a basic work related test to be ‘taxing’, its findings recommended the incorporation of physical fitness standard within the service and that consideration should be given to reducing the age of retirement (Gamble et al 1991). Regardless of the recommendations it is clear that there is considerable need for improving the fitness of road staff and that this in turn could reduce two of the most common causes of lost time due to sickness.

There are many other issues within the service which studies show are detrimental to the health. Although there is little data specific to the number of smokers within the service it is apparent that a large number of staff smoke and the negative health implications of that are widely reported.

With long hours on consecutive days and the regular reality of not receiving a break, preparing good food is very difficult. Whether the individual is nutritionally conscientious or not it is often more convenient to make poor nutritional choices whilst on the road meaning that many road staff have a very poor diet.

Further more, studies show that shift work can have detrimental effects on health pertaining to the disruption of circadian rhythms reducing the quality and quantity of sleep, leading to fatigue and other mental health problems as well as cardiovascular morbidity and mortality (Harrington 1994). The same study suggests that compressing the work week into twelve hour shifts so that there is regular weekly blocks of time off and correct shift scheduling can reduce risks but that working for prolonged periods 48 – 56 hours per week such as on the B relief rota has serious health and safety implications.

At the beginning of researching this Health Promotion study I had planned to briefly highlight the hypocrisy of asking the ambulance personnel to promote health and then draw on my previous knowledge to recommend health promotion strategies within the service in depth. The reality I have discovered is that there are so many negative health issues within the service that little justice can be given to the subject within such a short piece of work.

It is however clear that if we are to ask road staff to promote health to our patients that we must first promote health within the service.

Whist the list of initiatives would be vast and require the sort of ‘selfcare’ model being adopted by the NHS to create a cultural change within the service some basic initiatives can be began immediately.

If the model is to make every Technician & Paramedic a community champion of health promotion then perhaps each complex, each station, requires its own officer or elected champion of health promotion to inspire change from within.

This could range from simply helping individuals access health and fitness in their local area to the organisation of inter complex or inter-service sports competition with the added benefit of team building.

The promotion of complex or service-wide stop smoking weeks and more freely available information on NHS discounts relating to smoking cessation services would add a social support structure to any individual’s efforts and reduce issues over staff smoking on or near NHS properties.

Ultimately the inclusion of an annual fitness assessment and the provision of fitness facilities within stations whether it be through fitness professional lead sessions to onsite gyms would consolidate the services commitment to health promotion and may actual bring financial benefits due to increased productivity and reduced sickness (Lechner 1997). Studies show that exercise can improved intellectual functioning, physical fitness, emotional fitness, coping ability, and lowered risk of disease (Paffenbarger & Olsen 1996).

Whilst this may raise issues of equity with LAS staff have access to facilities and services not available to all it seems that health promotion needs to start somewhere and if we can do nothing but promote the health of our own workforce we will have made a difference. The hope and potential is however far greater. If we can influence the health and well being of our 5000 staff and the wider 1.43 million NHS staff so that they each “know the way, go the way and show the way” there will be no need to create initiatives to get staff promoting health advice, they will be empowered as champions of health in their own rights and they will enthusiastically promote lifestyle changes because of their own experiences. Yes, the LAS can deliver health promotion but the change must come from within.


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