Could the imminent launch of new standards for occupational health in construction mean that an industry with one of the poorest records on OH could, over time, blaze a trail for other sectors to follow? The launch of OH standards by Constructing Better Health (CBH) will succeed if managers in the industry gain a better understanding of occupational health.
The OH standards for the construction industry follow consultation on the draft standards published in June with industry, unions and occupational health providers. The standards evolved from an industry-led CBH pilot project between 2004 and 2006 in Leicestershire. CBH has the broad aim of protecting and improving the health of all UK construction workers for whom health outcomes are often significantly worse than other occupational groups.
The pilot aimed to raise awareness of OH issues and test out a model of delivery, and to use this experience to plan the design of a national scheme.
CBH offered small and medium-sized construction companies in Leicestershire free advice on health risk management, and a range of general health assessments. Uptake was good among the employers that took part.
While assessments were undertaken for a range of hazards, the results were not given to employers in any formalised process, so these were not used to assist with legal compliance or the health and safety framework.
An evaluation of the CBH pilot published in June 2007 by the Institute for Employment Studies (IES) found that while it was unclear how many of the employers involved in the pilot had engaged OH providers in the past, many appeared to report negative perceptions of OH provision.
Only one employer expressed any interest in undertaking statutory health assessments, but did not actually go ahead and undertake risk-based assessments. Employers favoured voluntary health assessments as health surveillance would involve them working with OH providers over time – an activity they regarded as expensive and ‘hit and miss’.
A medical inspector from the Health and Safety Executive (HSE) reiterated this when investigating hand-arm vibration health surveillance on a number of sites in Birmingham. He found that OH staff lacked qualifications and competency prior to the introduction of Faculty of Occupational Medicine-accredited courses for clinical assessment of hand-arm vibration syndrome. In addition, OH providers were not giving employers enough information to manage employees with health effects from vibration, and referrals to physicians were not followed up. In some cases, outsourced services for health surveillance were described by the inspector as very poor.
The IES report notes that while employees in the sector are interested in understanding more about their own health and how to protect it, there was “deeply held unwillingness” on the part of managers to take action to improve health outcomes for their employees.
The report concludes that OH interventions should focus on changes to management practices.
While these last points are unlikely to surprise many practitioners, it is likely that the greatest challenge will, as always, be working with those at the top of organisations to influence change.
One OH adviser to CBH commented that the standards “go right back to basics”. They set out in detail normal parameters for the range of health assessments. Many providers will be employing registered nurses or training OH technicians to undertake a range of tests.
While this may well be appropriate and a cost-effective means of addressing the dearth of qualified practitioners, the interpretation of health data and advice to management should remain the role of the competent, qualified OH practitioner.
One of the biggest challenges is providing OH for the many employees who work for small contractors. Larger firms that support the CBH scheme will have to provide services for smaller contractors down the supply chain.
Currently, there is no formal mechanism for sharing health information on fitness to work between employers. CBH has proposed as a solution that all health surveillance and fitness-to-work data will be stored on the current industry Construction Skills Certification Scheme (CSCS) smart card, which may be combined with a CBH health data card. Each time the card is updated, the information will be uploaded to CBH and the national database of construction workers.
Employers will pay a fee for data entry, and it is proposed that OH providers will pay a fee for registration and accreditation as approved suppliers to CBH.
The database will, over time, be used to provide information on health trends and statistical analysis of industrial disease and ill health in the sector. Employers will be able to access OH risk management information via the CBH website and a nurse-led call centre.
The standards propose that OH providers and nurse-led services are overseen and managed by Specialist Community Public Health Nurses on part 3 of the Nursing and Midwifery Council register. While it appears that some providers are unhappy about this element of the proposed standards, the HSE is clear that this is the level of competency required.
How will CBH standards be implemented?
The experience of many practitioners delivering OH services in the industry is that employers are most likely to do the bare minimum to achieve compliance and in the management of risk. Equally, most OH service provision is likely to be outsourced.
For the implementation of the standards to succeed in improving health outcomes, there must be effective communication of health processes across organisations. From the start, the aims and objectives of a proposed health risk management programme should be clarified and underpinned by the necessary resources and support from those with power and influence.
While this is understood by practitioners working in any industry sector, it appears the reality is that employers do not currently see the benefit of health surveillance, and are not always prepared to play their part in any overall programme of health risk management.
It is essential to explain the OH role to employers. There is a limited evidence base for health surveillance, which shows that it is effective only when implemented as part of a range of risk management measures. While practitioners know that OH processes cannot operate in a vacuum, many employers will need advice on the HR and health and safety structures which support health-related activities.
While health surveillance is undertaken on the basis of risk assessment and underpinned by a wide range of safety legislation, even the smallest organisations will need a policy that outlines how employees will be supported following an abnormal health result, and will need to consider redeployment opportunities as soon as an incident occurs.
The construction industry and allied sectors operate on a managed project basis, and often OH services are delivered at varied locations and on a project basis to reflect working patterns and limit the time staff are away from the workplace.
Undertaking health surveillance in construction is a very ‘hands on’ clinical role. OH providers will need a very practical approach to providing health information and recommendations to management about fitness to work. OH needs to gain an understanding of the varied roles and work processes, and this often involves analysing a range of core worker tasks to assess their impact on health.
While this might involve direct observation and some objective measurements, it also involves talking to employees about elements of their role. A reasonable level of knowledge of work processes will enable the practitioner to discuss how advice might be implemented, rather than making statements such as ‘fit for work with restrictions’, which is currently featured in the CBH standards ‘Fitness for Work’ criteria.
A more useful approach would be for occupational health to give general advice to review the risk assessment and/or advice on reduction of exposure to the specified hazard, rather than restricting the work activities of an individual. An exception to this is where the medical practitioner has advised that an individual be removed from exposure to the specified hazard following diagnosis of disease. In any case, the appropriate OH practitioner should give clear advice on the review and monitoring of health effects or symptoms.
The means to achieve the aims of CBH will be reviewed and refined over time. Many OH practitioners working in the construction industry will apply the standards and demonstrate how OH can add value in assisting with the reduction of retained risk and the incidence of industrial disease.
It will, in time, be possible to deliver a range of services to improve health outcomes for this occupational group, and it may yet be the construction industry that leads the way in the development of effective health risk management.
The Constructing Better Health Standards
The matrix of standards available from the CBH website provides information on a range of health assessments matched with specific job profiles. The proposed 21 standards are coded and identified as one of the following:
- Statutory health assessments.
- Strongly recommended assessments – possible legal requirement.
- Recommended – no legal requirement.
- Safety critical role worker assessments (a proposed ‘increased risk worker’ category has now been removed from the final standards).
Statutory health assessments underpinned by risk assessment or safety based activities – fitness for continued exposure to hazard. These include the following standards:
A Baseline health assessment to assess fitness before exposure/pre-employment
G Respiratory health
I Hand-arm vibration syndrome
K Biological monitoring
L Chest x-rays
R Information training and instruction
E Visual acuity
J Skin assessments.
Safety critical workers – fitness to work – all mobile plant operators, high-speed road workers, rail track side workers and others identified by risk assessment. In addition to other required statutory assessments, these include:
A Baseline assessment/pre-employment
B Blood pressure
D&F Visual acuity including colour
G Respiratory health
M Musculoskeletal assessment
P&R Drug and alcohol testing, routine urine test.
Case study: Setting up a health surveillance programme for Clancy Docwra
Clancy Docwra is a leading UK construction company, operating in the utility, transportation, power and infrastructure sectors. Following an initial pilot project and health surveillance programme, an OH service was implemented for three key areas of compliance, noise, vibration and skin assessments.
This obtained baseline health surveillance across seven of the company’s utility contracts from the Isle of Wight to the highlands of Scotland. All services were delivered from a mobile unit and using the client’s own facilities.
Data from the programme corresponds with the overall findings of the CBH Pilot Project.
Management briefings and training
Management briefings were held in advance of each phase of the programme for each contract management team. The OH team’s intention was to communicate the aims of the project and its objective of compliance. The possible outcomes in terms of data, results and the necessary management actions included advice on risk assessment from the safety team.
At the end of each phase of health surveillance, the broad findings were discussed with the same management team, including the hand over of ‘Fitness for Work’ statements. These detailed past and present exposure to the specified hazards, noise vibration and skin irritants.
Advice was given on the need to review the risk assessment and/or reduction of current levels of exposure. In addition, advice was given on review periods and referral to physician for definitive diagnosis of industrial disease.
Managers who did not attend management briefings were as likely to act on OH advice as those who did not. The difference was that it was more likely that there would be support for the programme at the level of contract manager and above. Direct communication with the operational manager by both the contract manager and the OH practitioners led to better co-operation and implementation of health advice.
Following the first phase of the project, training for management in their role in health management and what to expect from the OH team was delivered as a collaborative effort between HR, Safety and the OH team, and this considered OH advice, risk assessment and redeployment issues.
Overall, there was significant support from the health, safety and environment manager in influencing management actions on those contracts which were slow to implement OH advice.