Читать книгу Occupational Health Law - Diana Kloss - Страница 27

In the last 25 years there has been a sea change in the attitude of the British government to occupational health. A White Paper, The Health of the Nation, was published in 1992. Successive governments since the inauguration of the National Health Service after World War II had come to realise that spending on health care must be contained. The creation of an internal market by separating the authorities who provide health care from those who purchase it was one strategy to try to secure better value for money. Another was to try to encourage the population to take care of its own health. The White Paper demonstrated the government’s commitment to preventive medicine. It selected five key areas in which national targets were fixed. These were coronary heart disease and stroke, cancers, mental illness, HIV/AIDS and sexual health, and accidents.

The White Paper emphasised the importance of a healthy workplace and proposed the setting up of a task force to examine and develop activity on health promotion in the workplace. It also encouraged the NHS to set an example to other employers to show what can be achieved. The NHS Management Executive set up a task group of NHS managers, Health Education Authority representatives and professionals to review the way in which the NHS promoted the health of its own employees.

Further important proposals were initiated in 1998. A Green Paper Our Healthier Nation proposed a ten‐year strategy for occupational health, to be set out in a consultation paper from the HSC. The Occupational Health Strategy Unit within the HSE’s Health Directorate, set up in 1996, was charged with the responsibility of developing a national ‘vision for occupational health’.

At the same time there was a marked increase in the numbers of regulations governing health and safety at work, particularly those originating in European Community Directives. Many of these were designed to prevent long‐term injury to health, as compared to the prevention of accidental injury. Health professionals with the necessary training and expertise are especially valuable to employers who need advice on the implementation of the regulations and the provision of health surveillance to ensure that the employees are not suffering adverse effects from their work. Perhaps the most important of these regulations are the Management of Health and Safety at Work Regulations 1992, implementing the EC Framework Directive. These oblige all employers, with minor exceptions, to make a suitable and sufficient assessment of the risks to the health and safety of their employees, and to those not in their employment, arising out of the conduct of their undertakings. Every employer shall ensure that his employees are provided with such health surveillance as is appropriate. The Approved Code of Practice (since abandoned) advised that, at least in some instances, this would necessitate the services of ‘an Occupational Health Nurse’ or medical surveillance by ‘an appropriately qualified practitioner’. Taken with the emphasis in the regulations on the need to employ competent persons, it would seem that the employment of health professionals with specialist qualifications in occupational health was at last gaining official recognition. An Occupational Health and Safety Lead Body was established to develop vocational qualifications for health and safety practitioners.

Amendments to the Approved Code of Practice (no longer in force) accompanying the Management Regulations 1999 gave guidance on the appointment of competent persons. Paragraph 49 stated:

Employers who appoint doctors, nurses or other health professionals to advise them on the effects of work on employee health, or to carry out certain procedures, for example health surveillance, should first check that such providers can offer evidence of a sufficient level of expertise or training in occupational health. Registers of competent practitioners are maintained by several professional bodies, and are often valuable.

Competence does not necessarily depend on paper qualifications, but may also require an understanding of relevant best practice, an awareness of the limitations of one’s own experience and knowledge, and the willingness and ability to supplement existing experience and knowledge, when necessary, by obtaining external help and advice. A British Standard (BS 8800) was published in 1996: Guide to occupational health and safety management systems. BS 8800 is regularly updated. In 2018 a comprehensive International Standard was published: BS ISO 45001.

The Health and Safety Commission expressed one of its priorities as the establishment of the key points of attack in improving occupational health and identifying the extent of occupational ill health, taking appropriate action to exploit the linkages between occupational health and the government’s ‘Health of the Nation’ initiative.

The assessment and management of health risks – the central requirement of the various regulations – are often more complex or involve greater uncertainty than for occupational safety risks. Targeted guidance on assessment and management, and on selecting expert advice, will be needed by employers and employee representatives, as well as by health and safety inspectors, as an essential tool to ensure effective action.

The Commission planned to continue to give high priority to epidemiological research. A successful consultant‐based scheme for the collection of data relating to occupational lung disease was extended to a number of other work‐related diseases. Subsequently some GPs also became involved. This data collection scheme is now known as THOR (The Health and Occupation Reporting Network) and is administered by the Centre for Occupational and Environmental Health of the University of Manchester. More attention was paid to GPs, who may fail to identify the connection between a patient’s work and their medical condition. The Health and Safety Executive in 1992 produced a booklet on occupational health for family doctors: Your Patients and their Work and the Faculty and Society of Occupational Medicine and the Royal College of General Practitioners, supported by the Department for Work and Pensions, produced a joint publication: the Health and Work Handbook.

In 2000 the Department of the Environment, Transport and the Regions published a Strategy Statement (Chapter 5). It set out targets for reducing the number of days lost through illness and injury at work. The role of occupational health was seen as central to achieving this reduction. The HSC’s report, An Occupational Health Strategy for Great Britain (2001), set out a number of objectives. Interested parties planned to work together to achieve the following targets by 2010:

 a 20 per cent reduction in the incidence of work‐related ill health;

 a 20 per cent reduction in ill health to members of the public caused by work activity;

 a 30 per cent reduction in the number of work days lost due to work‐related ill health;

 that everyone currently in employment but off work due to ill health or disability is, where necessary and appropriate, made aware of opportunities for rehabilitation back into work as early as possible; and

 that everyone currently not in employment due to ill health or disability is, where necessary and appropriate, made aware of and offered opportunities to prepare for and find work.

A Partnership Board was set up to oversee the implementation and delivery of the strategy, and responsible to them was a Programme Action Group to facilitate the delivery of each of the strategy’s five programmes of work (compliance, continuous improvement, knowledge, skills and support mechanisms). Programme 1 (to improve the law in relation to occupational health and compliance with it) was the most relevant to this book. The aim was to encourage the important work of developing standards, or guidance on best practice, and to support occupational health legislation, as well as enforcing the law when appropriate. The priority areas included:

 improving the law by introducing agreed new and revised health‐related legislation and/or guidance and by removing unnecessary legislation;

 increasing the involvement of health and safety representatives;

 increasing fines/sentences and other disincentives to breaches of the law;

 increasing information on the economic benefits of addressing occupational health in order to help promote compliance;

 raising awareness of the law within priority groups (e.g. small firms);

 securing consistent enforcement action on health issues;

 increasing the involvement of interested parties (e.g. trade associations) to produce standards; and

 raising awareness among employers that reasonable adjustments to working arrangements should be made for employees or job seekers who are, or who become, disabled.

Programme 5 (to ensure that appropriate mechanisms are in place to deliver information, advice and other support on occupational health) was particularly relevant to occupational health professionals. The aim was to give everyone access to appropriate occupational health support. It planned to examine ‘the feasibility of new legislation on the accessibility and availability of occupational health support’ and ‘ensure that support is provided by professionally skilled people when appropriate’. One recommendation was to provide occupational health training for primary care teams.

In 2000, the Report of the Occupational Health Advisory Committee and Recommendations on improving access to occupational health support was published (OHAC Report). It made the point that changing patterns of employment mean that an increasing proportion of the working population are employed in small enterprises where there is no ready access to occupational health advice. The report drew comparisons with the position in other Member States of the European Union: from France where occupational health was very much grounded in occupational medicine, to Finland where all employers must have a multi‐disciplinary service, 50 per cent of the costs of which could be reimbursed through national sickness insurance.

The Committee reported that in the UK public sector almost half the total workforce had access to some form of occupational health advice, but that the picture was very different in the private sector. There was a decrease in the number of people covered by in‐house services. Indications were that smaller companies either did not use occupational health support at all or relied on GPs or nurses, some of whom were not trained in occupational health. EMAS, the HSE and local authority inspectors were a source of information and guidance, but their resources were stretched. Employers of small‐ and medium‐sized enterprises (SMEs) had little awareness of occupational health legislation.

Even where occupational health support was provided by employers, it was often viewed with suspicion by workers who saw it as being concerned mainly with sickness absence monitoring. ‘The fundamental issue is one of recognition that the prevention of work‐related ill health should form an essential aspect of the running of any organisation.’ Attention needed to be paid to tackle health inequalities throughout the workplace. Women, ethnic minorities and the disabled might need different treatment from other workers. There was a need for partnerships at local level. Occupational health support should be linked strategically with NHS and local authority initiatives. One example of such a partnership was the Sheffield Occupational Health Advisory Service which was developing a service to patients through the four Sheffield Primary Care Trust practices. It had created a Manual of Occupational Health in Primary Care. A similar organisation was Health Works in the London East End Borough of Newham.

There was debate about whether a change in employer behaviour could be brought about without new legislation to make the provision of occupational health support mandatory. Enforcement, however, would be challenging and the patchy availability of occupational health support would create difficulties in some areas.

The TUC supported the creation of a duty on employers to ensure that employees had access to individual medical advice. An alternative would be legislation to require mandatory self‐assessment and auditing by employers, with tax incentives for employers who performed well (a pilot scheme existed in Alberta, Canada).

One of the most effective incentives for individual organisations would be convincing evidence that the costs of ill health interventions would be outweighed by the benefits.

A project in South West Water concluded that the cost to the industry of work‐related ill health amounted to £8,650 for each worker affected. It might be that the imposition of a charge for the costs of the treatment of work‐related ill health through the NHS on employers’ insurance companies, leading to higher premiums, would make employers more careful. This would, however, be more effective for accidents than for diseases because the latter often take longer to develop and are difficult to attribute to a particular employer.

As regards the delivery of occupational health support there should be a three‐tiered approach. The first tier should involve the GP, safety representatives, trade unions, trade associations and so on. The second tier would be professional advice from, for example, a safety adviser, occupational health nurse with a basic qualification, or occupational hygienist. The top tier would be professional advice from a specialist, for example an experienced occupational physician (and, I suggest, an experienced OH nurse practitioner).

There should be more training for GPs in occupational health, certainly where they were contracted to provide OH services to employers without possessing even the basic qualification of the Diploma in Occupational Medicine. Primary care trusts should have available specialist expertise in occupational health and safety. Some larger practices might have a doctor or nurse recognised as an OH specialist. There were insufficient numbers of trained staff to support a national occupational health service provided through the NHS.

Worker support and involvement was central.

Employers need to secure the practical and enthusiastic commitment of their workforce to make sure that preventive approaches are actually implemented.

It was important that workers were not only consulted, but also given the opportunity to contribute proactively, especially in the process of risk identification.

In conclusion, there was not one solution by itself that would meet the occupational health support needs of everyone; flexibility was the key to delivery mechanisms.

Following the OHAC Report, a number of research reports were commissioned by the HSE, including The evaluation of occupational health advice in primary care (2004) and Review of occupational health and safety of Britain’s ethnic minorities (2004).