Under surveillance: an extract from Contemporary Occupational Health Nursing

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In the second of two extracts from the textbook Contemporary Occupational Health Nursing, Susanna Everton discusses the legal underpinning of health surveillance and the range of professionals involved.

The Control of Substances Hazardous to Health (COSHH) Regulations 2002 state that: "If an employee is exposed to a substance specified in sch.6 and is engaged in a process specified therein, the health surveillance required under paragraph (1) shall include medical surveillance under the supervision of a relevant doctor at intervals of not more than 12 months or at such shorter intervals as the relevant doctor may require."

Other legislation where medical surveillance is stipulated includes:

  • Asbestos at Work 2002: "Each employee who is exposed to asbestos is under adequate medical surveillance by a relevant doctor."
  • Lead at Work 2002: "Every employer shall ensure that each of his employees who is or is liable to be exposed to lead is under suitable medical surveillance by a relevant doctor."
  • Ionising Radiation 1999: ‘"The employer shall ensure that each of his employees to whom this regulation relates is under adequate medical surveillance by an appointed doctor or employment medical adviser for the purpose of determining the fitness of each employee for the work with ionising radiation which he is to carry out."

The appointed doctor – in practice, usually an occupational physician – will conduct a baseline examination and then regular clinical examinations of at-risk individuals and carry out any tests that may be required to ascertain their health, which may include blood and urine tests for lead levels.

The doctor must then decide on the fitness of the individual to continue working in the exposed environment and certify any entry on the health record.

Each regulation where medical surveillance is required gives detailed information on the full remit of the doctor, particularly regarding health records, asbestos licences and the Health and Safety Executive (HSE).

The doctor will also be involved in advising the employer on the future employment of an individual who is found to have an identifiable disease in alternative work.

The COSHH Regulation stipulates: "Where an employee is subject to medical surveillance in accordance with paragraph 5 and a relevant doctor has certified by an entry in the health record of that employee that in his professional opinion that employee should not be engaged in work which exposes him to that substance or that he should only be so engaged under conditions specified in the record, the employer shall not permit the employee to be engaged in such work except in accordance with the conditions, if any, specified in the health record, unless that entry has been cancelled by a relevant doctor."

More on health surveillance in the new book

This article is an excerpt from a chapter in Contemporary Occupational Health Nursing that includes sections on:

  • what health surveillance is and what it is not;
  • the legal, ethical and financial reasons for health surveillance;
  • hazard identification, risk assessment and workplace inspection;
  • the role of OH professionals in setting up and running health surveillance programmes;
  • how to work as part of the OH and safety team;
  • what records and record management are required for health surveillance; and
  • the principles of prevention and where personal protective equipment fits with health surveillance.

Health surveillance professionals

The COSHH Regulations 2002 require two specific roles when carrying out health and medical surveillance:

  1. The "appointed doctor" should be a registered medical practitioner who is appointed in writing by the HSE for the purpose of the regulation. There is also a legal requirement for employees exposed to lead, asbestos and ionising radiation at work to have regular health checks carried out by an approved doctor.
  2. The "employment medical adviser" refers to an adviser appointed under s.56 of the Health and Safety at Work etc Act 1974.

In addition to these two required roles, most health surveillance programmes are run and managed by OH advisers.

Guidance suggests that in its simplest form, health surveillance involves employees checking themselves for signs or symptoms of ill health. The caveat is that this must be part of a health surveillance programme and in circumstances where the employee has been trained in what to look for and informed of whom they should report symptoms to.

The OH adviser will need to demonstrate that he or she has the training and experience necessary to be able to set up a health surveillance programme, provide suitably qualified and experienced staff to carry out the work, be able to use and maintain any equipment necessary and provide the appropriate reports on employee fitness to enable the employer to conduct business.

The OH adviser will:

  • liaise with managers and health and safety officials in identifying the hazard and risks, and identify any employees exposed;
  • agree with the manager and staff representatives what health surveillance is appropriate in the situation;
  • arrange for the exposed group to receive education and be able to self-question and self-examine depending on hazard, and know when to refer to OH;
  • arrange for statutory medical examination if required;
  • arrange for health-screening schedules and appointments;
  • conduct any required screening;
  • manage the overall administration of the surveillance programme;
  • write individual reports and group statistical reports, and maintain the health record for the organisation; and
  • follow up with individuals.

In some OH settings an OH support worker is employed. An OH support worker has been defined by the Royal College of Nursing (RCN) as an individual who delivers OH services to and for individuals and groups.

The OH support worker will have the required level of knowledge and skills to recognise the influence of work on health, and will work under professional supervision within the guidance of established protocols and procedures. The OH support worker will perform agreed health screening and surveillance, which can include education and collection of screening data arising from worker activity.

The OH physician will conduct the statutory medical examinations, and can advise on the results of health screening. The details of the legal requirements of the doctor in health and medical surveillance can be found in the specific regulations.

According to new guidance from the British Medical Association, part of the OH support worker role is to: monitor the health of workers that are potentially exposed to hazards at work through health surveillance programmes; to analyse data from surveillance programmes using sound epidemiological methods to identify trends in worker health; and recommend any remedial measures necessary to improve worker health. The OH support worker can be available for opinion on referral to specialists.

An occupational hygienist may also form part of the OH team. The International Occupational Hygiene Association defines occupational hygiene as: "The discipline of anticipating, recognising, evaluating and controlling health hazards in the working environment, with the objective of protecting worker health and wellbeing, and safeguarding the community at large."

Occupational hygienists are specialists in the measurement of the personal exposure of a worker to a hazard or agent in their workplace, particularly at the relevant interface between the environment and the body – for example, the breathing zone, hearing zone and assessment of the data in terms of recommended workplace exposure limits, where such criteria exist.

OH teams will need to work very closely with safety professionals to have a coordinated approach to advising the employer in managing the occupational and safety risks in the organisation. The safety adviser will be able to offer assistance on assessing the hazard and risks, and will be expected to provide information on workplace inspections and alert OH if there is a problem that may need a health follow-up. The OH adviser should be able to provide information on potential workplace problems if a health issue is reported, and should then alert management.

Keeping records

The health record is not the same as the medical record. The health record is the non-confidential record of individuals’ exposure to substances or physical hazards that may be harmful to their health, and the health tests, procedures and examinations they have undertaken as part of health surveillance.

It is a statutory requirement under the various Regulations for an employer to hold such a record. The health record, as part of the health surveillance programme, will contain personal information – so it needs to be stored securely and be accessed only by those who need to know, and it is also subject to data protection legislation and should be kept by the employer.

Under the Data Protection Act 1998, employees must be informed that a health record for them exists, and that they have a right to access the information and correct it as necessary.

Health records should be held by and be available to managers even when separate occupational medical records are also kept. These records are sometimes held in OH departments. As they need to be accessible by managers when required, it is advisable to keep them separate from the individual’s medical records.

The health record needs to be kept for 40 years from the date of the last entry. All clinical information – as well as from medical consultations, test results and examinations, and OH adviser assessments, reports and referral letters – is to be kept in the individual’s personal medical file.

The HSE advises that health records allow outcome analysis of ill health, in relation to exposure at a later stage, should this prove necessary (required under reg.5 of the Management of Health and Safety at Work Regulations 1999, the duty on employers to monitor and review their control measures).

The health surveillance section on the HSE’s website has templates for the specific medical surveillances that can be adapted for any organisation.

For general use, the form must include the following:

  • the name and address of the employer;
  • the name and address of the employee;
  • the employee’s date of birth, their gender, their employee number and their national insurance number;
  • date the employee started work in the organisation;
  • the nature of employment;
  • details of any work exposure in their current employment;
  • details of any relevant exposure in previous employment;
  • information on any health surveillance carried out; and
  • the date and result of any health surveillance, any restrictions recommended, the unfit for work date where relevant, and the signature and status of the OH practitioner.

Health surveillance results

Where the health surveillance shows an employee has an identifiable disease or adverse health effect that is considered by a doctor – or in consultation with a doctor – to be the result of exposure to a hazardous substance or activity, then the employee’s manager will be notified.

The manager is then responsible for reviewing the risk assessment and any control measures, and improving where practical. The OH practitioner will notify the

employee of the results of the surveillance and provide him or her with any relevant information and advice regarding future health surveillance and how to manage his or her health – and this may require referral to the general practitioner or hospital specialist.

In discussion with the employee, the employer and staff representative, the individual may need to be assigned to different work to avoid or reduce exposure to the hazard. Analysis of an exposed group’s health surveillance results can be written up in the form of a statistical report for management, which can be used to gauge the effectiveness of control measures. This information can also be made available to the employees and staff representatives.

Conclusion

Health surveillance is a core activity in OH and is used as a process of systematically watching for early signs of work-related ill health in employees exposed to certain health risks.

In many settings, there is a statutory requirement to undertake health and/or medical surveillance and to keep appropriate records for 40 years after the last entry, but it can also be introduced if a particular health risk is identified.

It is primarily aimed at prevention and normally starts with a risk assessment of the hazard, which individuals might be harmed and how. It usually involves a set of questions and standardised tests, followed by the examinations of individuals in a selected exposed group.

It is also an opportunity for both the employer and employees to be informed and instructed in the hazard, any risk controls available and the health consequences. Those who show signs of health issues can be readily identified and measures put in place to prevent further harm.

It is vital, with any health surveillance programme, to ensure that all participants have a full understanding of what it entails and what happens with the results. This will include the employer and the selected employees, the staff representatives and the individual managers, as well as the OH team, health and safety professionals and OH hygienists.

Trends in ill health or emerging patterns in workplace hazards can then be demonstrated by health surveillance data.

To be effective, surveillance has to be followed by preventive action and an evaluation of the effectiveness of intervention (Hoh and Aw, 2003).

References

British Medical Association (2013). The Occupational Physician. London.

Data Protection Act 1998.

The Health and Safety at Work etc. Act 1974.

Hoh D, Aw T-C (2003). "Surveillance in occupational health". Occupational and Environmental Medicine; vol.60: pp.705-710.

Health and Safety Executive. Health surveillance.

Royal College of Nursing (2011). Roles and responsibilities of occupational health support workers. London; RCN.

The Chemicals (Hazard Information and Packaging for Supply) Regulations 2009.

The Management of Health and Safety at Work Regulations 1999.

The Registration, Evaluation, Authorisation and Restriction of Chemicals 2007.

Substances requiring surveillance

The substances listed under sch.6 of the Control of Substances Hazardous to Health Regulations 2002:

  • vinyl chloride monomer;
  • nitro or amino derivatives of phenol and of benzene or its homologues;
  • potassium or sodium chromate or dichromate;
  • ortho-tolidine and its salts;
  • dianisidine and its salts;
  • dichlorobenzidine and its salts;
  • auramine;
  • magenta;
  • carbon disulphide;
  • disulphur dichloride;
  • benzene, including benzol;
  • carbon tetrachloride;
  • trichlorethylene; and
  • pitch.

Source: Control of Substances Hazardous to Health 2002

About Susanna Everton

Susanna Everton RGN SCPHN(OH) ChSP MSc CMIOSH is an occupational health and safety practitioner.
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