Common deficiencies in OH service provision

The level of "competence" appropriate for such an adviser is dependent on the risks and complexity of the work process. As far as work-related health risks are concerned (as opposed to safety risks), employers may assume that they are meeting this obligation by employing qualified specialist occupational health nurses and physicians - referred to here as occupational health professionals (OHPs).

Employers that have directly employed or contracted such advisers are understandably perturbed when the Health and Safety Executive (HSE) informs them that they have not complied with regulatory requirements. Yet, in our experience, this occurs frequently when employers have not engaged fully enough with OHPs to ensure minimum legal compliance. In particular, the problem is exacerbated when legal responsibilities are not clarified or communicated between the main dutyholder, the human resources function and the health and safety advisers.

Risk assessment

HSE inspectors frequently find that the OHPs have not clearly informed their employers/clients that the dutyholder has an obligation to undertake a suitable and sufficient risk assessment for all workplace health risks. Extracts from relevant legislation (the Health and Safety at Work etc Act 1974, reg. 3 of the management Regulations and reg. 6 of the Control of Substances Hazardous to Health Regulations 2002) are reproduced in box 1.

Often, OHPs do not clearly explain, either during the tendering phase for a contract or subsequently, that assisting employers with this process is part of the competent advice that they are trained and qualified to provide. The relevant section of the Royal College of Physicians' Faculty of Occupational Medicine's guidance Good medical practice for occupational physicians, which lists activities expected of occupational physicians, is reproduced in box 2.

The well-established steps involved in conducting risk assessments, most recently spelled out in the HSE pamphlet Five steps to risk assessment, involve: identifying hazards; deciding who may be harmed and how; evaluating the risks and deciding on precautions; recording findings and implementing them; and regularly reviewing assessments and updating them, if necessary¹. OHPs are familiar with these steps, yet frequently we see that they fail to follow them rigorously. Too often, they fail to identify all hazards; or, when considering who may be harmed, they omit certain categories of worker, such as trainees, temporary staff, workers who have changed jobs in the same organisation and non-employees, such as contract workers. They frequently misconstrue occupational health provision to mean little more than providing health surveillance, whereas legal compliance requires that priority is given to eliminating and controlling exposure to hazards and that health surveillance is appropriate only where a residual risk of exposure remains after taking these actions.

Similarly, very few OHPs provide grouped, anonymised data on work-related adverse health effects to dutyholders. This feedback is necessary to enable employers to monitor and review the effectiveness of their control measures and should prompt a review of risk assessments where new cases of work-related ill health arise.

Ethical and professional considerations

Ethical and professional considerations are related areas where HSE inspectors find considerable cause for concern. Not infrequently, we see employees whose health has been adversely affected because they or their employer have not obtained the correct advice from their OHP.

While we are concerned about the ethical and professional standards in general occupational health service provision, only the specific requirements for doctors will be addressed here.

Ethical and professional concerns have been found in occupational health-screening programmes that are provided by OHPs, including occupational health technicians and occupational health nurses. In a proportion of these screening programmes, a significant number of employees may have been identified as having positive symptoms, or signs, of an occupational disease, but the appropriate referral for a competent diagnosis and arrangements for the necessary care are often not undertaken.

Instead, employees who are identified as having significant signs and symptoms may be referred to their own GP, who may not have the competence to undertake this specialist activity. Consequently, such employees are often left without an appropriate assessment to establish the diagnosis and remain exposed to the hazard, which - we have found - can lead to severe cases of occupational illness. In addition, this approach means that trends or groupings of affected employees are more difficult to identify and flag to the employer for action. Furthermore, the dutyholder does not receive notification of these conditions from a doctor, which would require them to notify the HSE under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.

Where the above circumstances are found, there is often no clearly defined or documented protocol as to when the occupational health nurse or technician should refer employees who have positive symptoms or signs to an occupational physician. Furthermore, in our experience of these circumstances, often none of the occupational health physicians, nurses or technicians considers that the setting up, writing or review of these protocols is their responsibility. Employees, as patients of the occupational health service, appear to "fall between two stools" and are left in a position that could jeopardise their health.

Why this situation occurs is difficult to ascertain, but we have encountered circumstances where occupational health nurses or technicians are directly employed by the dutyholder and accountable for the occupational health service budget. In such cases, there may be no direct line of clinical supervision and delegation of responsibility between the outsourced occupational health physician and the in-house OHPs. In addition, this may put the in-house OHPs under pressure not to refer staff for what is seen as expensive use of the visiting contracted occupational physician's time.

Failure of patient care has been recognised in multi-disciplinary and multi-agency health teams, where individual professionals may not clearly take responsibility for patient follow-through. The General Medical Council (GMC) has identified mental health teams as being particularly at risk, as the consequences can be potentially severe, where patients may harm themselves or others. The GMC has developed guidance for these circumstances entitled Accountability in multi-disciplinary and multi-agency mental health teams, published in October 2005 (see box 2 ), which specifically states: "Doctors should do their best to ensure that the systems in which they are working provide a good standard of care to patients. Where doctors cannot be satisfied, nor take steps to resolve problems, they should draw the matter to the attention of their NHS trust or other employing or contracting body."

We have been advised by the GMC (via personal communication) that it expects the principles of this guidance to be followed by all doctors and that its standards and ethics department intends to revise the guidance accordingly in the near future.

There are clearly aspects of clinical competence involved in occupational health service provision for which clinical responsibility should be allocated. OHPs provide screening and assessment of employees - during which diagnoses are made, medications may be prescribed (commonly immunisations) and further investigations are initiated - which require interpretation and actioning. In the past, doctors took the lead role for clinical responsibility for patient/employee care. However, the boundaries in clinical management are changing and other qualified occupational health personnel may be considered able to take on this responsibility. In such cases, clinical responsibility for employee/patient assessment and care should be clearly stated in individual job descriptions/employment contracts. Where doctors are allocated clinical responsibility, they may need to delegate this to occupational health nurses or other staff in their absence, as they frequently attend the department on a part-time basis.

The GMC's guidance on delegation for doctors is covered in section 46 of Good medical practice, as follows:

"Delegation involves asking a nurse, doctor, medical student or other healthcare worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved. You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient."

It is good practice for the delegation of clinical responsibilities to be set out in a written protocol by the doctor and agreed by all concerned. In the OH setting, this would include responsibilities such as fitness-for-work assessments with pass and referral criteria, management of suspected work-related ill-health cases detected during health surveillance and any treatment given.

In the case of fitness-for-work assessments, this usually covers procedures such as consulting previous occupational health records held in the department on the applicant in order to ascertain whether any history was relevant to the assessment. It would contain advice on questions that should be asked or further reports that should be obtained from other doctors. In addition, it would identify the conditions that should be referred for special investigations and assessment by the occupational physician before advice on fitness for work can be safely given.

For screening programmes in the occupational setting, the Faculty of Occupational Medicine advises that "the programme must incorporate an appropriately competent physician to interpret these findings and make any necessary arrangements for further care" (see box 2).

The Department of Health's guidance for doctors who delegate treatment to other health professionals recommends that doctors provide documented "patient group directions" to allow staff other than doctors to provide treatment without individual prescriptions².

In summary

We suggest that OHPs carefully consider their employment contract with dutyholders, as the boundary between professional and contractual obligations may be blurred. We recommend that OHPs clearly point out to employers what the occupational health and safety legislation requires and how their specialist training and qualifications can assist employers in achieving this. It is preferable that this advice is documented, so that it can be referred to at a later stage should questions about areas of responsibility arise, such as during an HSE investigation. If an employer chooses not to accept the advice that has been offered (outside of the usual requirements for attendance management and ad hoc advice on individual employees), this should be documented in the contract.

Unless the contract specifies otherwise, the employer may reasonably assume that the OHP is providing a comprehensive service, as would be expected of someone with specialist qualifications and experience. For doctors, this should be within the ethical guidance of the GMC and of the Faculty of Occupational Medicine. The HSE may also assume this and may consider enforcement or prosecution under s.36 of the Health and Safety at Work etc Act 1974 against individual practitioners, where ill health has arisen and has been found to be because of non-compliance with the law, as a result of a lack of advice (which a competent OHP should have provided).

In addition, the HSE has a memorandum of understanding with the GMC that, where inspectors feel that there are ethical concerns or that a doctor's practice is putting the health of the employee population at risk, they should refer the physician to the GMC³.

References

1. Five steps to risk assessment, INDG163(rev2), www.hse.gov.uk/risk .

2. See www.mhra.gov.uk  in the section on patient group directions in the A-Z index.

3. A memorandum of Understanding (PDF format, 124K) (on the HSE website), January 2004. 

Dr Anne Raynal, HM senior medical inspector, MBChB, MSc, NEBOSH Dipl Occ H&S, MFOM, and Helen Sherwood, HM inspector health and safety, BA, PG Dipl Occ H&S, MIOSH, wish to thank members of the HSE's Corporate Medical Unit, Health Sector, Employment Medical Advisory Service and Health Unit for their constructive criticism of this article. The views expressed do not necessarily reflect those of the corporate Health and Safety Executive or Commission.