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       Hazards special online report, December 2015
HSE defends its impotence in the losing battle against work’s diseases
The Health and Safety Executive (HSE) has a legal duty to provide a medical service, making sure our bodies aren’t chockful of deadly substances or otherwise wrecked at work. But, finds Hazards editor Rory O’Neill, its medical division is nearing extinction, the whole occupational medicine profession could follow suit and the UK’s workplace diseases crisis is continuing unchecked.

The mines are near enough finished, steelworks are moth-balled and manufacturing is mostly mechanised or elsewhere. It explains in a large part the long-term decline in workplace fatalities.

But that doesn’t mean the danger has passed. Health and Safety Executive (HSE) statistics published in October 2015, show 2 million people in Great Britain currently have a health problem caused or made worse by work. The figures for 2014/15 show 1.2 million of these had worked in the last 12 months. Half a million had developed their condition in the preceding year. Work-related ill-health accounted for nearly six times as many working days lost (23.3 million) as workplace injuries (4.1 million).

And there is a trend. Year-on-year figures vary, but the general trend under the Conservative’s plan for HSE has been up.

HSE figures show since the Conservatives defeated Labour in 2010/11, self-reported work-related illness has increased by 7 per cent, up from 1.16m cases to 1.24m in 2014/15.  For stress and musculoskeletal disorders, which make up 80 per cent of the work-related total, long-term and new cases are up. The musculoskeletal disorders figure in 2010/11 was 515,000. By 2014/15, it was 553,000 – up 7.3 per cent. For stress, anxiety and depression, cases were up from 402,000 to 440,000, an increase of 9.4 per cent.

It is an effect confirmed for England in the latest preliminary Marmot indicators from the Department of Health-supported Institute for Health Equity, published on 27 November 2015. These note: “The positive downward trend for work-related illness seen between 2009/10 and 2011/12 for England reversed in 2013/14, when 4000 people per 100,000 (4 per cent of workers) employed reported a work-related illness, up from 3,640 in 2011/12.”

Announcing the findings, IHE director Professor Sir Michael Marmot noted: “We know poor conditions at work, such as long or insufficient hours, low pay, low control over tasks and insecure contracts can lead to increased risks of poor physical and mental ill health… our findings suggest that there is more that local employers and government can do to encourage, incentivise and enforce good quality work to support good health. Poor quality jobs will cost the health service more in the long run.”

The economic downturn put many of us under the cosh at work, with job pressure up and job security down. We needed a regulator to defend us. We didn’t get one.

Medical examination

There have for years been concerns about a dangerous haemorrhage of staff from HSE’s medical wing (Hazards 100).  The service had 120 staff in the early 1990s, half doctors and half nurses. By 2012, HSE’s Corporate Medical Unit (CMU) was reduced to two and a bit occupational physicians and 18 nurses (Hazards 120).

Comparisons are now a little more complicated, after a 2015 reorganisation ordered by new HSE chief executive Richard Judge. Under the restructuring, medical staff employed by HSE’s lab wing HSL and its old CMU medical wing – now merged into a broader HSE Science Directorate – are counted together.

DOCTORED  In a 25 November 2015 email, HSE chief science adviser Professor Andrew Curran told Hazards the medical division was this year absorbed into a wider science unit at HSE, combining the medical capabilities across the organisation. He spelled out HSE’s current – dramatically curtailed – medical capability. More.

HSE chief scientific adviser Professor Andrew Curran, in a 25 November 2015 email response to Hazards,  said this combined head count runs to 5.6 full time equivalent doctors, a full time occupational health nurse and a respiratory nurse specialist, and a team of 13 occupational health inspectors (OHIs) and two principle inspectors, all of whom are qualified nurses. This amounts to an occupational health workforce within HSE of 22.6 staff.

However you count it, HSE is not maintaining an in-house medical service anywhere near the size of that of previous years. An annex to a 5 September 2007 paper to HSE’s board headed ‘Corporate Medical Capabilities Review’, provides the evidence confirming HSE’s medical expertise has been severely eroded across the entire organisation. It notes that in June 2007, HSE and HSL combined employed 10 full time equivalent doctors, and 26.4 full time equivalent OHIs.

In less than nine years, the number of doctors on HSE’s staff has fallen by 44 per cent. Nurse numbers are down from a total of 26.4 to 17, a fall of over a third (35 per cent), and the overall HSE in-house medical capability has dropped from 36.4 to 22.6 staff, or a drop of 38 per cent.

Compared to the service provided in the early 1990s, HSE is now serving a greatly expanded labour force with less than one-fifth the in-house medical expertise.

The watchdog is required by law to provide occupational medicine expertise and medical surveillance to keep tabs on worker exposure to some of the deadliest substances – including lead, asbestos and other carcinogens - and workplace environments around.

But, according to at least one well-placed individual with insider knowledge, HSE is falling down on the job. Anne Raynal, a former HSE senior medical inspector, says HSE neither polices how firms respond to health threats at work nor meets its own monitoring duties.

In a November 2015 editorial in the British Medical Journal (BMJ), the veteran occupational physician warns “occupational medicine is unlikely to survive as a specialty because of a lack of enforcement of the employers' duty not to harm the health of their workers by the Health and Safety Executive.”

The article, titled ‘Occupational medicine in demise,’ notes that Great Britain is the only major country in Europe that does not have a legal requirement for occupational health services, either by the state or employer, which would find these diseases early, she explains.

According to Raynal: “Only 0.3 per cent of the 500,000 annual incidences of work related ill health, estimated from the Labour Force Survey, are reported to the HSE. However, no prosecutions have been brought for not reporting occupational diseases or related deaths under the statutory regulations in the past five years.”

SILICA SAGA  Companies are continuing to expose workers to excessive levels of silica dust, which can cause deadly cancers and lung diseases, raising serious concerns about Health and Safety Executive (HSE) prevention campaigns. More

A lack of resources certainly explains some of the difficulties faced by HSE. Raynal notes that when HSE was created in the mid-1970s, HSE’s medical wing “was envisaged to have 100 full time equivalent doctors.” Now across all of HSE, the watchdog has just one-tenth that number.

It’s not just about what HSE does, it is also about what it knows. With greatly reduced medical activity, the government’s workplace health regulator has precious little intelligence on which workplaces are making their workers sick and how.

Nor are HSE’s field inspectors picking up the slack. Preventive inspections have all but ended and for at least one of the big beasts – workplace stress – HSE has taken no enforcement action at all in recent years (Hazards 128). According to Stress-related and psychological disorders in Great Britain 2014, an October 2014 report from the HSE: “The rates of work-related stress, depression or anxiety, for both total and new cases, have remained broadly flat for more than a decade.”

Other health risks languish in the HSE ‘failed’ column. HSE has failed consistently to address effectively the risks posed by silica, which include the frequently deadly silicosis and lung cancer, an occupational hazard with which the pharaohs were familiar.

The wrong medicine

The Health and Safety Executive (HSE) says Raynal is wrong to put the blame at its door. “The UK health and safety system places the responsibility to control health and safety risks resulting from work activities with the employer,” responded HSE’s chief medical adviser Professor David Fishwick and chief science adviser Professor Andrew Curran.

“This ‘goal based’ self-regulatory approach not only enables industry to innovate (e.g. introducing new materials, processes or technology) by developing effective risk control measures without the need for changes to regulation, but it also has led to the UK being one of the safest places to work in Europe”.

In a rapid online response to the BMJ article, subsequently published in BMJ on 3 December 2015, they state: “We disagree with the view of former HSE Senior Medical Inspector Dr Anne Raynal and the situation she describes as being directly linked to a lack of occupational health doctors working in HSE.”

The HSE rebuttal notes the UK is “best in class” for safety statistics in Europe and has among “the lowest rates of workers taking time off due to work-related illness.” However, they present no evidence of HSE’s interventions leading to improvements in occupational health, only pointing out that latex and isocyanate related cases of occupational asthma are down and that both had been “the focus of HSE led preventative approaches.”

Others argue that HSE’s contribution has been more modest than claimed, even on these showcased examples. Unions, for example, have pressed for and won measures to remove risks posed by latex and isocyanates over many years. Nursing unions have run long-standing campaigns on latex safety. Union pressure for safer alternatives to isocyanates, including workplace bans, goes back decades and were featuring the TUC’s 1995 book, ‘Asthma at work: Causes, effects and what to do about them.’

Stirling University’s Andrew Watterson, a professor of occupational health, believes the HSE rebuttal addresses neither Raynal’s “key points nor contests any of her statistics on occupational medicine’s demise within the HSE… It is of course difficult to defend the indefensible.”

Also responding in the BMJ, Watterson says “HSE is locked into management jargon that fails to answer the charges made against it. In several respects such language compounds the problem and reveals further inadequacies in its policies and practices. A ‘goal-based self-regulatory approach’ for HSE could easily be viewed as a mechanism for justifying staff and resources cuts especially within HSE occupational medicine.

“This again would support Dr Raynal’s analysis of no prosecutions for not reporting occupational diseases or related deaths under statutory regulations in the last five years. However, the evidence for self-regulation goals as a substitute for effective regulation in occupational health and safety is minimal and may cloak all manner of shortcomings.”

 UK’s work-related sick leave record doesn’t look so rosy when you find out it is “on a par with Italy” but “worse than Romania, Bulgaria, Malta, Greece, Lithuania, Turkey and Ireland,” he adds.

“There is mention, rightly, of some good occupational health work underway in the HSE but the big picture failures are yet again glossed over or ignored.”

Medical issues are not prominent in HSE’s management structure, and neither HSE chief medical adviser David Fishwick or chief science adviser Andrew Curran are on HSE’s management board. While HSE may argue its medical function is enhanced by greater inter-disciplinary work within the Science Directorate, the regulator risks reinforcing the message that occupational medicine is invisible and unimportant within HSE.

It is not just Raynal that believes HSE’s commitment to occupational medicine is waning, and could be taking the rest of the profession with it.

One letter published by BMJ in response to the Raynal article described occupational medicine in the UK as being in a “parlous state”. Another, from specialist occupational physician Paul Nicholson and Nigel L Wilson of the British Medical Association’s occupational health committee, noted: “The Health and Safety Executive (HSE) Employment Medical Advisory Service has been decimated over recent decades, and this may have reduced demand for specialist occupational physicians.”

Nicholson and Wilson added: “We believe that action is needed on several fronts to increase both supply and demand for specialists in occupational medicine. These actions include enforcing current regulation by the HSE…”

CLASS ACT?  Don’t think employers will step in with a cure, when HSE’s medics are nowhere to be seen. Studies show lower status jobs tend to come with much higher safety and health risks – but a major international study found where there are workplace health interventions, they are twice as likely to target those on higher rungs of the workplace ladder. More.

Raynal says HSE can’t have it both ways. HSE says it believes the responsibility lies with employers to self-regulate, but it doesn’t act when they fail in that responsibility. Instead, she says, employers have found a wholly different function for occupational medicine. It is one concerned with controlling legal liability, not health risks.

She says this transfer of loyalties from aiding the worker to aiding their employer avoid disability discrimination or unfair dismissal claims “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 and the concomitant rise in medical indemnity insurance premiums”.

Employers get what they want, because “almost all doctors working in occupational medicine in Britain are paid by employers, including in the NHS, which is a conflict of interest.” The result? “Occupational physicians have been actively discouraged from identifying cases of work related ill-health, with evidence of their having careers threatened or ended,” Raynal notes.

She warns: “Doctors working in occupational medicine are beholden to employers, who have little incentive to find or prevent occupational diseases.”


Marmot indicators 2015, Institute for Health Equity, 27 November 2015.

Anne Raynal. Editorial: Occupational medicine is in demise, British Medical Journal, volume 351:h5905, published online 11 November 2015. BMJ news release.

Andrew Curran and David Fishwick. Demise of occupational medicine: Health and Safety Executive’s response to article on the demise of occupational medicine, British Medical Journal, volume 351:h6452, 3 December 2015.

Andrew Watterson. Demise of occupational medicine: Health and Safety Executive’s failed record on occupational medicine, British Medical Journal, volume 351:h5905, 3 December 2015.



Doctored: HSE's medical headcount

In a 25 November 2015 email, HSE chief science adviser Professor Andrew Curran told Hazards the medical division – previously known as the Employment Medical Advisory Service (EMAS) and then the Corporate Medical Unit (CMU) -  was in 2015 absorbed into a wider science unit at HSE, combining the medical capabilities across the organisation and creating a wider, inter-disciplinary resource.

“Richard Judge, HSE’s chief executive, decided to create a Science Directorate, by bringing together the capabilities in HSE’s Corporate Science, Engineering and Analysis Directorate and HSL, from 1 April 2015.

“The new Science Directorate is seen as vital to and wholly in harmony with HSE’s plans. Revitalised science lies at the heart of HSE’s evidence based approach to policy making and risk management and having this capability ‘in-house’ gives HSE some significant advantages as a modern regulator. In particular, it enables HSE to combine medical resources from HSL and HSE into a single team of occupational and disease specific physicians for HSE led by our Chief Medical Adviser. This is equivalent to 5.6 full time equivalent doctors, with 3.1 occupational physicians and 2.5 disease specific doctors (respiratory and musculoskeletal). The employment model is mixed and includes both directly employed physicians and joint appointments with local NHS Trusts.

"In addition to the physicians, there is a full time occupational health nurse and a respiratory nurse specialist in this team. HSE also has a team of occupational health inspectors (all of whom are qualified nurses). HSE also appoints approximately 400 physicians to act as their agents in the field for the management of various regulations.”


Old hazard, same old HSE failure

Companies are continuing to expose workers to excessive levels of silica dust, which can cause deadly cancers and lung diseases, raising serious concerns about Health and Safety Executive (HSE) prevention campaigns.

An HSE inspection initiative visited 60 stone businesses, including work surface manufacturers, stonemasons and monumental masons, in the period from June to September 2015. It found a failure to control the potentially lethal dust was commonplace. The initiative, supported by trade association, Stone Federation Great Britain, found serious breaches at over half (35) of the premises that were visited, with inadequate control of respirable crystalline silica (RCS) one of the “common areas of concern… found throughout the initiative”.

HSE told Hazards that most of its enforcement action – three out of four prohibition notices and 36 of 54 improvement notices – related to a failure to control silica exposures. HSE said “a number of businesses” were unaware that in 2006 the workplace exposure limit for respirable crystalline silica was revised from 0.3 mg/m3 to 0.1mg/m3, requiring more stringent controls. In a clarification to Hazards, the watchdog said “at least 7” of the 60 businesses were unaware of the tighter standard, “however feedback was not sought from all inspectors on this point.”

HSE has over many years known about the problem, but failed repeatedly to implement a solution (Hazards 126). This pattern of HSE ineffectiveness has been exposed repeatedly by the regulator’s own reviews.  Its 2009 baseline study found that all the major industries with a potential for high silica exposures, including the stone industry, were failing to control the risks.

An HSE ‘Clear the Air!’ campaign the same year warned construction workers about the dangers of silica exposure after it found smaller companies knew very little about the health risks. But a 2014 HSE construction site inspection blitz found the runaway top health risk was still silica exposure (Hazards 127).


Unhealthy class bias in workplace health initiatives

Studies show low pay lower status jobs tend to come with much higher safety and health risks. So, it might come as a surprise that workplace health interventions are twice as likely to target those on higher rungs of the workplace ladder.

Researchers from Dusseldorf University’s faculty of medicine examined workplace interventions aimed at benefiting the health of the workforce that have been published in journals across the world. They found 36 in total, grouping interventions into those aimed at weight loss, healthy eating, preventing or supporting those with stress, and musculoskeletal disorders.  The authors of the study, whose findings were published last year in the Scandinavian Journal of Work Environment and Health, note that health interventions at work should target those in lower “socioeconomic positions”, because they are known to have both the worst general health and the most unhealthy jobs.

“Occupational groups with lower qualifications and occupational positions generally suffer from poorer health than those in higher positions,” they report. “As the quality of work and employment follows the same pattern of social distribution as health, leaving those in lower socioeconomic positions (SEP) in more stressful jobs, there is a clear need to prioritise worksite interventions among occupational groups with lower socioeconomic standing and their specific occupational exposures.”

The study infact found over twice as many interventions were aimed at the higher skilled occupational groups such as managers, than at the lower skilled ones. In the case of stress, those in the higher grades were more than three times as likely to have an intervention aimed at helping them than the lower skilled groups. For MSDs, they were nearer 10 times as likely to have an intervention.

The authors conclude “the challenge of reducing work-related health inequalities by targeting health-promoting activities at occupational groups with high needs remains largely unmet.”

• D Montano, H Hoven, J Siegrist. A meta-analysis of health effects of randomized controlled worksite interventions: Does social stratification matter?, Scandinavian Journal of Work Environment and Health, volume 40, number 3, pages 230-234, 2014.

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Doctor? No

The Health and Safety Executive (HSE) has a legal duty to provide a medical service, making sure our bodies aren’t chockful of deadly substances or otherwise wrecked at work. But, finds Hazards editor Rory O’Neill, its medical division is nearing extinction, the whole occupational medicine profession could follow suit and the UK’s workplace diseases crisis is continuing unchecked.

•  Introduction
•  Medical examination
•  The wrong medicine
•  References

Related stories
•   Doctored: HSE's medical headcount
•  Old hazard, same old HSE failure
•  Unhealthy class bias in workplace health initiatives

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