Cancer risk in information technology workers: a UK Biobank study.

BACKGROUND: The information technology (IT) workforce has been growing more rapidly than others, with occupational health (OH) risks of sedentary behaviour, physical inactivity and poor diet, yet studies of their non-communicable disease risk, notably cancer, are lacking. AIMS: To investigate cancer risk in IT workers compared to others in employment and the nine major Standard Occupational Classification (SOC) groups. METHODS: We evaluated incident diagnosed cancers in the UK Biobank cohort through national cancer registry linkage. Cox proportional hazard regression models, with 15-year follow-up, were used to compare incident cancer risk among IT workers with all other employed participants and with the nine major SOC groups. RESULTS: Overall, 10 517 (4%) employed participants were IT workers. Adjusting for confounders, IT workers had a slightly lower cancer incidence compared to all other employed participants (Model 2: hazard ratio = 0.91, 95% confidence interval [CI] 0.83-1.01). Compared to the nine major SOC groups, they had a similar (Major Groups 2, 5 and 8) or lower (Major Groups 1, 3, 4, 6, 7 and 9) cancer incidence. CONCLUSIONS: Despite their occupational risks of sedentary behaviour, poor diet and physical inactivity, IT workers do not have an increased cancer incidence compared to all other employed participants and the nine major SOC groups. This study paves the way for large, longitudinal health outcome studies of this under-researched and rapidly growing occupational group.

Health, lifestyle and occupational risks in Information Technology workers.

BACKGROUND: Information technology (IT) and the IT workforce are rapidly expanding with potential occupational health implications. But to date, IT worker health is under-studied and large-scale studies are lacking. AIMS: To investigate health, lifestyle and occupational risk factors of IT workers. METHODS: We evaluated self-reported health, lifestyle and occupational risk factors for IT workers in the UK Biobank database. Using logistic regression, we investigated differences between IT workers and all other employed participants. Regression models were repeated for IT worker subgroups (managers, professionals, technicians) and their respective counterparts within the same Standard Occupational Classification (SOC) major group (functional managers, science and technology professionals, science and technology associate professionals). RESULTS: Overall, 10 931 (4%) employed participants were IT workers. Compared to all other employed participants, IT workers reported similar overall health, but lower lifestyle risk factors for smoking and obesity. Sedentary work was a substantially higher occupational exposure risk for IT workers compared to all other employed participants (odds ratio [OR] = 5.14, 95% confidence interval [CI]: 4.91-5.39) and their specific SOC group counterparts (managers: OR = 1.83, 95% CI: 1.68-1.99, professionals: OR = 7.18, 95% CI: 6.58-7.82, technicians: OR = 4.48, 95% CI: 3.87-5.17). IT workers were also more likely to engage in computer screen-time outside work than all other employed participants (OR = 1.42, 95% CI: 1.35-1.51). CONCLUSIONS: Improved understanding of health, lifestyle and occupational risk factors from this, the largest to date study of IT worker health, can help inform workplace interventions to mitigate risk, improve health and increase the work participation of this increasingly important and rapidly growing occupational group.

Peer review audit of non-specialist occupational physician reports.

BACKGROUND: With declining specialist occupational physician (OP) numbers, there is increasing recognition of the importance of non-specialist physicians in occupational health (OH) service delivery, yet to date, this physician group remains understudied and their competency requirements poorly understood. AIMS: To evaluate the quality of a sample of non-specialist OH reports and compare these with specialist reports. METHODS: A retrospective peer review audit of a convenience sample of 200 consecutive non-specialist and specialist OH reports from an Irish OH service using an assessment form based on the modified Sheffield Assessment Instrument for Letters SAIL(OH)1. RESULTS: Of the 200 peer reviewed OH reports, 159 (80%) were from non-specialists. For all questions, 87% and above of non-specialist reports were 'satisfactory' or 'above expected'. On the overall assessment, out of 10, the mean non-specialist report score was 6.8 (standard deviation (SD) 3-10) and the specialist score was 7.3 (SD 3-10). Comparatively, non-specialist reports highlighted legal/ethical issues marginally more and adhered slightly better to contractual/ethical/legal boundaries, while specialist reports fared better in addressing manager's questions, in their structure and clarity and in covering all significant aspects of the case, particularly if the case was complex. CONCLUSIONS: Our findings demonstrate a high standard of OH report quality in this sample of non-specialist OPs that is consistent across all key OH report components. Potential development areas are also identified that can inform education/training tailored to this physician group and assist in competency standard-setting.

Research and teaching activity in UK occupational physicians.

BACKGROUND: For all doctors, including occupational physicians (OPs), research and teaching are considered core requirements of medical education and continuing professional development. Academic skills are also vital to evidence-based practice and advancement of occupational health (OH) as a specialty. In recent years, attention has focussed on the declining UK OH academic base and the research- practice gap, and increased practitioner participation in research is encouraged. AIMS: To establish a baseline of research and teaching activity among UK OPs, identify related barriers and inform strategies to overcome them. METHODS: An online survey including specific career profile questions derived from consensus following expert panel discussions. It formed part of a larger Delphi study on UK OH research priorities. RESULTS: We received 213 responses, about 18% of 1207 practising UK OPs. Of these, 162 (76%) undertook research at some career-point, of which 44 (27%) were currently research-active. Similarly, 154 (72%) undertook teaching at some career-point, of which 99 (64%) were currently teaching-active. Of those who had never undertaken research (n = 51) or teaching (n = 59), 40 and 42% were interested in doing so, respectively. Key barriers were lack of time and opportunity, the former particularly for respondents practising in industry, where 'commercial' demands take priority, rather than healthcare. CONCLUSIONS: This study establishes a benchmark of academic activity among UK OPs and identifies related barriers. These 'target' barriers can shape research funding priorities and education to increase participation and develop the UK OH academic base.

Healthy workers or less healthy leavers? Mortality in military veterans.

BACKGROUND: The 'healthy worker effect' predicts that longer employment is positively associated with reduced mortality, but few studies have examined mortality in military veterans irrespective of exposure to conflict. AIMS: To examine mortality in a large national cohort of Scottish veterans by length of service. METHODS: Retrospective cohort study comparing survival in up to 30-year follow-up among 57 000 veterans and 173 000 people with no record of service, matched for age, sex and area of residence, who were born between 1945 and 1985. We compared antecedent diagnoses in the two groups to provide information on probable risk factors. RESULTS: By the end of follow-up, 3520 (6%) veterans had died, compared with 10 947 (6%) non-veterans. Cox proportional hazard analysis confirmed no significant difference overall unadjusted or after adjusting for deprivation. On subgroup analysis, those who left prematurely (early service leavers) were at significantly increased risk of death (hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.09-1.24, P < 0.001), although the increase became non-significant after adjusting for socioeconomic status (HR 1.05, 95% CI 0.99-1.12). Longer-serving veterans were at significantly lower risk of death than non-veterans; the risk decreased both with length of service and in more recent birth cohorts. Smoking-related disease was the greatest contributor to increased mortality in early leavers. CONCLUSIONS: Among longer-serving veterans, there was evidence of a HWE partly attributable to selective attrition of early service leavers, but birth cohort analysis suggests improvements over time which may also reflect a causal effect of improved in-service health promotion.

Working Health Services Scotland: a 4-year evaluation.

Background: Working Health Service Scotland (WHSS) supports the self-employed and employees of small and medium-sized enterprises (SMEs) in Scotland with a health condition affecting their ability to work, who are either absent or at risk of becoming absent due to it. Aims: To evaluate the impact on health and work outcomes of WHSS clients over a 4-year period. Methods: Data were collected at enrolment, entry, discharge and follow-up at 3 and 6 months after discharge. Clients completed up to three validated health questionnaires at entry and discharge-EuroQol five dimensions (EQ-5D) and visual analogue scale (VAS); Hospital Anxiety and Depression Scale (HADS); and Canadian Occupational Performance Measure (COPM). Results: A total of 13463 referrals occurred in the 4-year period; 11748 (87%) were eligible and completed entry assessment and 60% of the latter completed discharge paperwork. The majority of referrals were due to musculoskeletal conditions (84%) while 12% were referred with mental health conditions. Almost a fifth (18%) of cases were absent at entry and back at work at discharge. Work days lost while in WHSS was associated with age, length of absence prior to entering WHSS, primary health condition and time in programme. All health measures showed significant improvements from entry to discharge. Improvement in general health was sustained at 3- and 6-month follow-up. Conclusions: The WHSS evaluation findings indicate that participation was associated with positive changes to health and return-to-work. The extent of the positive change in health measures and work ability can be highly important economically for employees and employers.

Hand-arm vibration in orthopaedic surgery: a neglected risk.

Background: Hand-arm vibration syndrome is an occupational disease caused by exposure to hand-arm transmitted vibration. The Health and Safety Executive has set limits for vibration exposure, including an exposure action value (EAV), where steps should be taken to reduce exposure, and an exposure limit value (ELV), beyond which vibrating equipment must not be used for the rest of the working day. Aims: To measure hand-arm transmitted vibration among orthopaedic surgeons, who routinely use hand-operated saws. Methods: We undertook a cadaveric study measuring vibration associated with a tibial cut using battery-operated saws. Three surgeons undertook three tibial cuts each on cadaveric tibiae. Measurements were taken using a frequency-weighted root mean square acceleration, with the vibration total value calculated as the root of the sums squared in each of the three axes. Results: A mean (SD) vibration magnitude of 1 (0.2) m/s2 in the X-axis, 10.3 (1.9) m/s2 in the Y-axis and 4.2 (1.3) m/s2 in the Z-axis was observed. The weighted root mean squared magnitude of vibration was 11.3 (1.7) m/s2. These results suggest an EAV of 23 min and ELV of 1 h 33 min using this equipment. Conclusions: Our results demonstrate that use of a battery-operated sagittal saw can transmit levels of hand-arm vibration approaching the EAV or ELV through prolonged use. Further study is necessary to quantify this risk and establish whether surveillance is necessary for orthopaedic surgeons.

Core competencies for UK occupational health nurses: a Delphi study.

BACKGROUND: Occupational health nurses (OHNs) play a pivotal role in the delivery of occupational health (OH) services. Specific competency guidance has been developed in a number of countries, including the UK. While it is acknowledged that UK OHN practice has evolved in recent years, there has been no formal research to capture these developments to ensure that training and curricula remain up-to-date and reflect current practice. AIMS: To identify current priorities among UK OHNs of the competencies required for OH practice. METHODS: A modified Delphi study undertaken among representative OHN networks in the UK. This formed part of a larger study including UK and international occupational physicians. The study was conducted in two rounds using a questionnaire based on available guidance on training competencies for OH practice, the published literature, expert panel reviews and conference discussions. RESULTS: Consensus among OHNs was high with 7 out of the 12 domains scoring 100% in rating. 'Good clinical care' was the principal domain ranked most important, followed by 'general principles of assessment & management of occupational hazards to health'. 'Research methods' and 'teaching & educational supervision' were considered least important. CONCLUSIONS: This study has established UK OHNs' current priorities on the competencies required for OH practice. The timing of this paper is opportune with the formal launch of the Faculty of Occupational Health Nursing planned in 2018 and should inform the development of competency requirements as part of the Faculty's goals for standard setting in OHN education and training.

Trends in NHS doctor and dentist referrals to occupational health.

BACKGROUND: Ill-health in doctors can affect performance and fitness to practice, and consequently patient care and safety, placing an important responsibility on National Health Service (NHS) occupational health (OH) services. Anecdotal discussions amongst NHS occupational physicians suggest an increase in the number of doctor attendances over time, with continuing focus on mental illness. AIMS: To analyse OH referrals in doctors and dentists over 3 years. METHODS: A retrospective evaluation of all doctor and dentist referrals to the OH service in one Scottish NHS board from April 2011 to March 2014, comparing this to management-reported sickness absence (SA) data held by the organization. RESULTS: We found no significant change in overall OH referrals for doctors and dentists during the evaluation period. Mental illness was the commonest referral reason in all 3 years at 32, 38 and 30%, respectively, but no significant change in mental health referrals was demonstrated within the study period. SA events significantly increased during the three study years (356, 426 and 469, respectively; P < 0.05). OH referrals for those absent from work increased significantly between Years 1 and 3 (16 and 30, respectively; P < 0.05). CONCLUSIONS: SA events and OH referrals for those absent from work significantly increased between April 2011 and March 2014, but there was no commensurate (statistically significant) increase in overall OH referrals. These findings do not support anecdotal suggestions of increasing OH (or mental ill-health) attendances but can be used as a benchmark for other NHS organizations and for future trend comparisons.

Impact of peer review audit on occupational health report quality.

BACKGROUND: In a previous report, we described the implementation of a formal process for peer review of occupational health (OH) reports and a method of assessment of the outcomes of this process. The initial audit identified that 27% of OH reports required modifications. AIMS: To assess formally, following implementation of this process, if changes in practice had occurred, i.e. whether fewer deficiencies were being identified in reports. METHODS: We repeated a prospective internal audit of all peer reviewed OH reports between September and November 2011. We used an abbreviated assessment form, based on questions 4-8 and 10-12 of the modified SAIL (Sheffield Assessment Instrument for Letters), with four possible outcomes: no action, no changes made to report following discussion with author, changes made without discussion with author and changes made following discussion with author. RESULTS: One hundred seventy-three reports by 10 clinicians were audited. The audit identified a 13% reduction in OH reports requiring modifications (from 27 to 14%) compared with the previous cycle. Where modifications were required, 8% of these were related to minor typographical, spelling and grammar errors and 6% were for more complex reasons. Implementation of this process also produced a reduction in clinical complaints about OH reports from customers, from three in the preceding year to none 2 years later. CONCLUSIONS: Peer review improved the standard of OH reports and was associated with a reduction in customer complaints about reports.

Doctor and dentist contacts with an NHS occupational health service.

BACKGROUND: There is increasing acceptance that management of ill-health in doctors can be patchy and is not always optimal. Health can impact on performance and fitness to practice, placing an important responsibility on occupational health (OH) services. AIMS: To improve our understanding of OH contacts by doctors and dentists and make some comparison of this with available sickness absence records. METHODS: A retrospective descriptive evaluation of all doctor and dentist encounters with the OH service between April 2009 and March 2010 was undertaken. Doctor and dentist encounters from our electronic appointment system were analysed using Microsoft Excel. Comparisons were made with management-reported sickness absence data for this period. RESULTS: Blood tests, immunizations/immunization updates accounted for 49% (295) of contacts. Management and self-referrals accounted for 26% (157) of all OH contacts. Mental health conditions were the main reason for referral (approximately one-third of all cases referred). In this group, a much higher number presented to OH, absent from work, than were recorded with sickness absence by management. Musculoskeletal, infection and skin complaints were other predominant reasons for referral. CONCLUSIONS: Doctors and dentists do utilize this OH service and the issues for which they need services are wider than those of mental health. Inconsistency in the reporting of sickness absence in doctors with mental health problems has also been highlighted. This baseline information is a useful stepping stone to identifying and meeting the specific needs of doctors and dentists and can be used as a benchmark in other organizations.

Peer review audit of occupational health reports--process and outcomes.

BACKGROUND: Peer review is widely used in the selection and publication of scientific research. Its application in clinical practice is emerging, particularly with increased emphasis on clinical governance and the imminent introduction of revalidation. AIMS: To formalize our peer review process of occupational health (OH) reports and formally assess the outcomes of this process. METHODS: A prospective internal audit was carried out of all peer reviewed OH reports between June and August 2010. An abbreviated assessment form, based on Questions 4-12 of the Sheffield Assessment Instrument for Letters (SAIL) was utilized. The report was assessed using the abbreviated SAIL, with one of four possible outcome options-no action, no changes made to report following discussion with author, changes made without discussion with author and changes made following discussion with author. RESULTS: The audit identified that 27% of OH reports required modifications. Eighteen per cent were related to typographical errors, spelling, grammar and administrative fields being incomplete. Nine per cent were related to more complex reasons, most commonly, all the manager's questions not being addressed, review arrangements not being clear and the report not being clear and understandable to the intended readership. CONCLUSIONS: Peer review can be a useful tool in improving the standard of OH reports, specifically picking up minor errors and potentially more significant areas of concern. It can also be a valuable educational tool in terms of personal feedback, benchmarking and exposure to different styles of report writing.

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

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

Dental practitioners and ill health retirement: a qualitative investigation into the causes and effects.

INTRODUCTION: Data published in 1999 from the Government Actuary on the National Health Service Pension Scheme (1989-1994) have indicated that the frequency of ill health premature retirement (IHR) was four times more prevalent among dentists at age 42 years compared with doctors.Objective The aim of this project was to determine the factors that contributed to IHR in dental practitioners, and the effects of IHR on their lives. METHOD: Semi-structured interviews were carried out during 2007. A topic list was developed, piloted and used to guide the interviewer. A purposive sampling technique was used to recruit the respondents from an insurance company database. A framework approach to data analysis was utilised. RESULTS: Twenty-three respondents were interviewed, 19 male and 4 female, aged between 39-59 years. Depression, stress and anxiety were reported by respondents to be major causes of their retirement, followed by musculoskeletal disease and premature disability caused by trauma. This is illustrated by the following: '...just went straight into general practice but with some regrets. Practice was so depressing' (GDS/NHS); 'I withdraw, I don't engage ... I found it more and more difficult and one morning... I collapsed in tears at the practice' (GDS/NHS). Dentists reported both negative and positive comments in relation to support received from their health insurance company. CONCLUSIONS: The main causes of IHR were depression, musculoskeletal disease and specific skin conditions. Respondents expressed concern regarding the level of support available to dentists in distress. Respondents to this study found that continuing to work had a positive impact on their health.

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

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

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

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

Good medical practice: guidance for occupational physicians.

Following a catalogue of serious, highly publicized medical misdemeanours, the General Medical Council (GMC) has introduced plans for a new system of medical licensing in the UK called 'revalidation'. Under this, the onus will fall on individual doctors, including occupational physicians, to demonstrate their continuing fitness to practice. Doctors will need to show that they meet basic minimum standards in terms of the care they provide, their own continuing professional development, and other aspects of professional life like probity and ethical behaviour. As part of the process, the Faculty of Occupational Medicine, Royal College of Physicians, has produced its own guidance on good medical practice for occupational physicians, following an extensive consultation exercise. This paper summarizes the background to the initiative, the development process and the standards that have been recommended to aid professional accountability.

Health and neuropsychological functioning of dentists exposed to mercury.

OBJECTIVES: A cross sectional survey of dentists in the west of Scotland and unmatched controls was conducted to find the effect of chronic exposure to mercury on health and cognitive functioning. METHODS: 180 dentists were asked to complete a questionnaire that included items on handling of amalgam, symptoms experienced, possible influences on psychomotor function, and the 12 item general health questionnaire. Dentists were asked to complete a dental chart of their own mouths and to give samples of urine, hair, and nails for mercury analysis. Environmental measurements of mercury in dentists' surgeries were made and participants undertook a package of computerised psychomotor tests. 180 control subjects underwent a similar procedure, completing a questionnaire, having their amalgam surfaces counted, giving urine, hair, and nail samples and undergoing the psychomotor test package. RESULTS: Dentists had, on average, urinary mercury concentrations over four times that of control subjects, but all but one dentist had urinary mercury below the Health and Safety Executive health guidance value. Dentists were significantly more likely than control subjects to have had disorders of the kidney and memory disturbance. These symptoms were not significantly associated with urinary mercury concentration. Differences were found between the psychomotor performance of dentists and controls after adjusting for age and sex, but there was no significant association between changes in psychomotor response and mercury concentrations in urine, hair, or nails. CONCLUSIONS: Several differences in health and cognitive functioning between dentists and controls were found. These differences could not be directly attributed to their exposure to mercury. However, as similar health effects are known to be associated with mercury exposure, it would be appropriate to consider a system of health surveillance of dental staff with particular emphasis on symptoms associated with mercury toxicity where there is evidence of high levels of exposure to environmental mercury.

Training the assessors for the General Medical Council's Performance Procedures.

From July 1997, the General Medical Council (GMC) has had the power to investigate doctors whose performance is considered to be seriously deficient. Assessment procedures have been developed for all medical specialties to include peer review of performance in practice and tests of competence. Peer review is conducted by teams of at least two medical assessors and one lay assessor. A comprehensive training programme for assessors has been developed that simulates the context of a typical practice-based assessment and has been tailored for 12 medical specialties. The training includes the principles of assessment, familiarization with the assessment instruments and supervised practice in assessment methods used during the peer review visit. High fidelity is achieved through the use of actors who simulate third party interviewees and trained doctors who role play the assessee. A subgroup of assessors, selected to lead the assessment teams, undergo training in handling group dynamics, report writing and in defending the assessment report against legal challenge. Debriefing of assessors following real assessments has been strongly positive with regard to their preparedness and confidence in undertaking the assessment.