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Occupational medicine is in demise

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5905 (Published 11 November 2015) Cite this as: BMJ 2015;351:h5905
  1. Anne Raynal, independent occupational physician, UK
  1. occdoc{at}doctors.org.uk

The British Health and Safety Executive is failing in its statutory duty to protect workers from occupational disease

More than 13 000 deaths a year in Britain are directly attributable to occupational exposures, the Health and Safety Executive (HSE) says.1 These are mainly from cancers (predominantly related to asbestos) and respiratory diseases (caused by dusts and chemicals). Fewer than 15% of all working British people are likely to have access to occupational health services.2

Britain is the only major European country that does not have a legal requirement for the provision of occupational health services, by the state or employers. The Health and Safety at Work etc Act 1974 implies a duty on the employer based on risk,3 but this is minimally enforced.

In other major European countries occupational health services are either incorporated into national health and social services for all working people or are statutorily required through risk based insurance levies on employers, who are obliged to purchase comprehensive occupational health, rehabilitation, and compensation services from independent providers.3

Statutory reporting of occupational disease in Britain started in 1895. In 1973 the government brought all doctors who were part of the Factory Inspectorate into the Employment Medical Advisory Service (EMAS).4 EMAS was tasked with overseeing high risk industries (box) and was envisaged to have 100 full time equivalent doctors. Today it has only two medical inspectors for the whole country.

Regulations under the Health and Safety at Work etc Act 1974 that require medical surveillance

  • Control of Lead at Work Regulations 2002 (regulation 10)

  • Control of Substances Hazardous to Health Regulations 2002 (amended) (11(2)(a))

  • Control of Asbestos Regulations 2002 (21), 2006 and 2012 (22)

  • Ionizing Radiation Regulations 1999 (24)

  • Diving at Work Regulations 1997 (15)

  • The Work in Compressed Air Regulations 1996 (10)

Regulations under the Health and Safety at Work etc Act 1974 that require health surveillance

  • Control of Substances Hazardous to Health Regulations 2002 (amended) and 2003 (11)

  • Management of the Health and Safety at Work Regulations 1999 (6)

  • Control of Noise at Work Regulations 2005 (9)

  • Control of Vibration at Work Regulations 2005 (7)

  • Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (4, death; 5, disease) and 2013 (6, death; 8, disease)

Currently, the only statutory medical surveillance for the early detection of work related ill health is provided by the HSE’s approved doctors, who cover about 40 000 workers in the most risky industries (box)—just 0.13% of the 30 million working people. The HSE has not prosecuted any employers for not providing statutory medical surveillance for workers exposed to asbestos in the past decade.5

Only 0.3% of the 500 000 annual incidences of work related ill health, estimated from the Labour Force Survey,6 are reported to the HSE.7 However, no prosecutions have been brought for not reporting occupational diseases or related deaths under the statutory regulations in the past five years.5

Employees are unlikely to be aware that they have an occupational disease because general practitioners are not trained to differentiate conditions related to work from other conditions. Affected workers and taxpayers pick up 80% of the costs of work related ill health.6

The demise of occupational physicians?

During both world wars the value of occupational physicians for providing advice on fitness for work and rehabilitation for injured servicemen was recognised during periods of personnel shortage. Rehabilitation was subsequently incorporated into the duties of EMAS, which set up a large number of successful industrial rehabilitation units.4 8 But these were disbanded by the late 1990s.8 Only recently has the dearth of a national rehabilitation service been recognised, in Carol Black’s review of the health of Britain’s working age population.9 The Department for Work and Pensions responded by introducing a telephone based, nurse led advice service, with minimal clinical diagnostic resources, to primarily provide advice on sickness absence to enable work retention.

Other than for the 0.3% of cases that they report, employers perceive that they are not obliged to keep records on cases of new occupational disease,10 which would require them to establish causation, using the relatively costly skills of doctors. By contrast, employers are aware that they are obliged to record all injuries.

Almost all doctors working in occupational medicine in Britain are paid by employers, including in the NHS, which is a conflict of interests. In contrast to doctors who report specified infectious diseases, occupational physicians have no statutory protection for doing their ethical duty. Lack of legal protection leads to job insecurity. Occupational physicians have been actively discouraged from identifying cases of work related ill health, with evidence of their careers having been threatened or ended.11 12

Occupational physicians have seen a huge shift in skills required, from using clinical abilities to detect and prevent work related ill health at the earliest opportunity to helping employers avoid unfair disability discrimination or dismissal claims. The duty of care of occupational physicians may not be primarily to the patient in this context.13

This is reflected in the near doubling of referrals of occupational physicians to the General Medical Council for alleged unethical conduct, from 40 in 2006 to 92 in 2012 (J Mauldridge, personal communication) and the concomitant rise in medical indemnity insurance premiums.

Job insecurity and high stress

In recent years trainees specialising in occupational medicine have fallen to a third of the number required to maintain the specialty.14 The discipline attracts the opprobrium of being regarded as the employer’s agent for managing personnel problems,4 which has job insecurity and high stress levels.

Furthermore, advising on other doctors’ patients is not thought to require diagnostic skills; hence services provided by nurses are seen as more cost effective, as reflected in the Department for Work and Pensions’ new programme.15 Most employers now use occupational health nurses to undertake the majority of the medical assessments that would have been done by occupational physicians 20 years ago.

British occupational medicine is unlikely to survive as a specialty because of the lack of enforcement by the HSE of employers’ duty not to harm the health of their workers.

The ethos of the 1802 Factory Act—that the state has a duty to protect workers who have no control over their working environments4—has been reversed. Doctors working in occupational medicine are beholden to employers, who have little incentive to find or prevent occupational diseases.

Notes

Cite this as: BMJ 2015;351:h5905

Footnotes

  • I thank Morris Greenberg, previous senior medical inspector at HSE, for his guidance and support, as well as other previous medical inspectors who wish to remain anonymous

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I was employed by the HSE as a medical inspector between January 2001 and November 2005 and as a senior medical inspector between December 2005 and October 2011.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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