Most organisations still do not have an occupational health service.
Whether you are setting up a new service or changing the focus of an existing one, a structured approach will assist in achieving this.
Organisations may vary in size, culture and structure, but the initial approach to establishing the type of occupational health service ap- propriate to a particular organisation is often the same. Some essential questions need to be asked to ensure that an occupational health service meets the needs of the organisation. What are the business objectives of the organisation? What are the business objectives of individual depart- ments? What are the key health and safety legislation issues? Are there any litigation concerns? How can employee health affect the foregoing?
It is also important to understand the culture of the company, along with how it is structured to achieve its objectives. The culture of the organisation affects the style of communication – formal written com- munications or oral contact; the dress code – formal or casual; decision- making – whether through committees and senior management or individuals retaining some autonomy; management style – whether they expect obedience or individual initiative; and so on. The culture is also likely to affect the structure of the organisation; it may have many levels of management or it may have achieved a ‘flat’ structure. Irrespec- tive of the style of structure, it is important for the occupational health professional to understand the lines and levels of communication.
As already mentioned, it is important that an occupational health service understands and is subject to the same business criteria as the rest of the organisation. All too often an occupational health nurse can be heard to say: ‘My manager does not understand what occupational health does!’ Should not that nurse instead be asking, ‘Do I understand what the organisation needs?’, it being all too easy simply to implement a programme because ‘it seemed like a good idea’ as it follows the broad principles of occupational health. Therefore, it is essential that the setting up of an occupational health service is carefully planned and commu- nicated. This is equally important whether the organisation is a large multinational or a small local family firm, with the approach remaining the same. One approach discussed in this chapter has separate elements involving five stages: assessment, planning and control, endorsement, implementation and monitoring.
Assessment
This is a critical element in the setting-up of an occupational health ser- vice, and needs to be carried out by occupational health staff whether
1. Meet the key personnel on-site and obtain a family tree, e.g. general or senior manager/director; human resources director/manager; health and safety manager;
reporting manager; senior management team; trade union convenor; wages/salaries manager; company secretary/legal manager.
2. Obtain a breakdown of the workforce by age, sex, white/blue-collar workers and job category, e.g. display screen equipment workers; fork-lift truck drivers; food handlers.
3. Obtain sickness/absence policy and determine procedures. Specific details should include:
r sickness/absence rate
r number of employees on long-term absence
r procedure for frequent short-term absence
r procedure for return from illness
r procedure for ill-health retirement
r procedure for monitoring work-related illness and injuries.
4. Determine current pre-employment procedures.
5. Arrange a site visit to understand the working processes and obtain a list of products on-site.
6. Assess exposure to health hazards and obtain any relevant risk assessments, e.g.
under Control of Substances Hazardous to Health and Manual Handling Regulations.
Hazards may include:
r chemical r biological r physical r mechanical r psychosocial.
7. Assess compliance with health and safety legislation and hygiene standards: wearing of personal protective equipment; training; notices.
8. Identify health related benefits provided to employees, e.g. Private Medical Insurance (PMI).
9. Assess first aid facilities.
10. Obtain details of compensation claims against the company for the past ten years.
11. Determine expectations of managers and employees for an occupational health service.
Figure 1.1 Occupational Health Assessment Checklist
they are commencing a new service or taking over or developing an ex- isting one. The staff needs to ascertain where they are now, where they need to be and how they are going to get there. To gain this understand- ing, many questions need to be asked and a knowledge of the culture of the organisation acquired. This involves much discussion with all areas of the organisation and may be quite time-consuming. It is therefore useful to have a checklist to assist in the process of assessment, and an example can be found in Figure 1.1.
Key Personnel Key personnel must be identified as a priority to ensure that nothing is missed when investigating the needs of the or- ganisation. To assist in this, the construction of a ‘family tree’ of the organisation showing the organisational structure can be an invaluable
aid; key personnel include the human resources manager, health and safety manager, general manager, reporting manager and union repre- sentatives.
Initially, close cooperation is likely to be required with the human re- sources department to investigate the organisation’s health-related poli- cies, and subsequently to operate effective health-related programmes.
Such programmes may include policies on smoking, alcohol and drugs, AIDS and health surveillance. An important issue for most organisations is the absence-management policy, and the way this is operated needs to be established. Is there a formal written policy? Who is responsible for managing it – managers or the human resources department? How is occupational health seen in respect of supporting it? Is the practice of proactive intervention supported?
Early contact with those responsible for health and safety is also nec- essary to establish the organisation’s approach to health and safety, the existence of health and safety policies, and to provide access to existing risk assessments under health and safety legislation. It may also be nec- essary to clarify areas of responsibility, as occasionally these may appear to overlap in the areas of safety and occupational health.
For the majority of occupational health services the reporting man- ager is likely to be within the human resources or health and safety department. In either case it is preferable that this person should be a member of the organisation’s board or have direct access to the board.
Discussions with senior and middle managers provide an opportu- nity to understand the business objectives of the organisation, and to initiate an understanding with the managers about how an occupa- tional health service can benefit them. Similarly, discussions with union representatives promote an understanding of the benefits that an occu- pational health service brings to their members. Support from all levels of the organisation is crucial for the success of the occupational health service, and the various expectations need to be identified.
Other personnel within the organisation may also be able to provide valuable information. The wages and/or salaries manager may shed light on absence-recording issues, whereas someone in the insurance or legal department may be able to advise on compensation claims that have been taken against the organisation by employees. This can be an important measurable benefit to the company, as health programmes can be put in place to minimise the risk of claims; for example, if there are claims for noise-induced deafness it is important to ensure that there is a functioning hearing conservation programme in place.
Structure and Demographics of the Organisation The family tree has already been mentioned as a useful tool for providing the occupa- tional health professional with an understanding of the organisation;
however, this needs to be broken down further to obtain informa- tion about certain specifics of its profile. The family tree includes
demographic information such as age, sex and ethnic minority dis- tribution along with the types of workers, i.e. white or blue-collar, and their job categories. Decisions can then be made on the health programmes that will be most suitable and most effective for the organ- isation, including health surveillance and voluntary health screening programmes. For example, there is little point in investing time and resource in a ‘well-woman’ programme if 95 % of the workforce is male.
Absence Management It is important to understand how the organ- isation sees the role of human resources, line managers and the occu- pational health service in this procedure; therefore, the existence of any formal written policies needs to be established before recommendations can be made. Knowledge of specific details includes: absence statistics and procedures for recording absence; procedures for employees report- ing absence; procedures for managing employees on long-term absence (e.g. over two or three weeks); procedures for managing employees with frequent short-term absences; procedures for seeing employees return- ing to work after absence; procedures for ill-health retirement (discus- sions will likely need to take place with the pensions manager); and procedures for monitoring work-related illness and injury.
This is an important area for the involvement of the occupational health service, as it can again provide some measurable benefits to the organisation. However, it also has to be recognised that these bene- fits cannot be delivered by occupational health alone, but only in co- operation with managers and/or human resources departments.
Pre-Employment Procedures An understanding of the organisa- tion’s recruitment procedures is required. In some organisations the process allows forward planning, and the procedure can be well con- trolled; whereas with others the process may require mass recruitment within 24 hours. The occupational health service must be able to respond to these requirements while ensuring the company is not laying itself open to future litigation related to health issues. Therefore, careful con- sideration needs to be given to the style of questionnaire to be used, the point at which the prospective employee needs to complete it (before or after a job offer) and who sees it. In addition, the requirement for a full medical examination – depending on whether there are any pension issues involved – or baseline screening needs to be ascertained.
Site Visit The occupational health staff needs to have a good under- standing of the working processes of the organisation, which can only be gained through visiting all areas of operation with personnel who understand the process and are able to explain it. Through this, an un- derstanding of the extent of machinery and equipment used on-site, along with any products, is gained, and a start made on determining
the presence of health hazards. Where a site is extensive or contains many different processes it is useful to obtain a site plan.
While undertaking site visits, hazard and risk identification may be carried out, along with assessment of compliance with health and safety legislation and good hygiene practice.
Hazard and Risk Identification A structure is provided under the Management of Health and Safety at Work Regulations 1999, which re- quires all organisations to carry out a general risk assessment to identify health and safety hazards in their workplace. This provides an excellent format for looking in more detail at the health hazards in the work- place and for deciding the requirement for health surveillance, health education and other health programmes. Where risk assessment is not available, the issue of non-compliance must be highlighted to the or- ganisation.
The general risk assessment should highlight the need for further detailed risk assessment under other health and safety legislation, in- cluding: Control of Substances Hazardous to Health Regulations 2004;
Workplace (Health, Safety and Welfare) Regulations 1992; Health and Safety (Display Screen Equipment) Regulations 1992; Provision and Use of Work Equipment Regulations 1998; and Manual Handling Operations Regulations 1992.
When carrying out a risk assessment it is necessary first to identify the presence of any hazards, which may be chemical, biological, physical, mechanical or psychosocial. Once the hazards have been determined, the risk of their actually causing harm can be assessed – which is where an in-depth understanding of the products and processes is required. If a risk has been established then a full programme must be instigated, starting with elimination of the hazard where at all practicable. The ini- tial part of the programme is likely to be under the control of safety and/or operations staff – where elimination of the hazard has proved impossible this involves control measures, maintenance of control mea- sures, staff training and the monitoring and recording of training, con- trol and maintenance measures. Generally ‘historical’ hazards such as noise and asbestos are well controlled, but have been replaced by ‘new’
ones such as vibration and stress, for which programmes for control are still being evaluated. Where appropriate, health surveillance is carried out to monitor the health of the employees, which will be managed by occupational health. They may also be involved in training.
Compliance with Health and Safety Legislation All qualified oc- cupational health staff must be fully conversant with current health and safety legislation, so that when carrying out an occupational health as- sessment they are able to identify where there may be non-compliance and to advise management, particularly in respect of health issues.
Non-compliance may be identified where there is poor hygiene prac- tice, including the non-wearing of personal protective equipment, and lack of warning notices, inadequate training programmes and the ab- sence of risk assessments and safe systems of work.
Reporting of work-related illness and injury under RIDDOR (Report- ing of Injuries, Diseases and Dangerous Occurrences Regulations 1995) is likely to require the input of occupational health. It must be ensured, therefore, that the organisation’s procedure for this includes occupa- tional health.
First Aid In many organisations the management of first aid in the workplace is often the responsibility of the occupational health service, so a full assessment of the current facilities and procedures needs to take place, including whether there is a formal first aid policy in existence.
The assessment should look at the following areas in relation to the organisation’s full first aid risk assessment required under the Health &
Safety (First Aid) Regulations 1981: the numbers and distribution of first aiders; whether all first aiders are in possession of an up-to-date First Aid at Work certificate; the number and location of first aid boxes and eye-irrigation facilities; the contents of the first aid boxes; the location and contents of a first aid room, if this is required; the procedures for recording the treatment of illness and injury; and the procedures for the disposal of casualties.
Report Once the assessment is completed, a full report needs to be compiled, which forms the baseline for the service and provides the basis for decisions when producing the occupational health strategy.
This remains an important historical document, as it provides findings and makes recommendations that, once priorities have been defined, may have to wait for some time before being implemented if resource is limited.
Planning and Control
Some occupational health services within organisations today appear to lack focus, such that resources are often under-utilised or ineffective, leading to a lack of credibility with both senior management and the workforce. This generally derives from a lack of planning and control.
Planning is normally the act of setting down expectations of what should happen, whereas control is the process of coping with changes when they occur.
After the assessment has been carried out, and a better understand- ing of the organisation achieved, the planning stage of the approach to setting up an occupational health service can proceed, which aids de- cisions on the strategy for the service. This is developed by looking at the available resources and deciding on the service requirements and
SERVICE
RESOURCES PLANNING
AND CONTROL
SERVICE REQUIREMENTS AND CUSTOMERS Figure 1.2 Planning and Control
number and type of customers, so that the service is able to respond to the demand (see Figure 1.2).
Resources This is the most important factor in planning and control, as resources automatically impose constraints on any decision-making.
These include numbers of staff, available equipment and the facilities for the occupational health department. When setting up an occupational health service, resources may already have been fixed by the organisa- tion, or else there may be an opportunity to start with a ‘clean sheet’, although the former situation is more common. If this is the case then resources are more likely to influence priorities; however, in the case that there is a ‘clean sheet’, priorities may be able to influence resources.
When looking at staffing, the correct skill mix needs to be assessed according to the size and culture of the organisation, the presence of identified hazards, the structure for managing health and safety, and any specific requirements of the organisation. Where there is an occupa- tional health team or an occupational health nurse working in isolation, the nurse in charge will hold an occupational health qualification and, preferably, will have management experience. The occupational health team may be led by the occupational health nurse or an occupational physician, with the rest of the team comprising other qualified occu- pational health nurses, occupational health nurses in training, clinical nurses, occupational health technicians, physiotherapists and adminis- trative assistants or secretaries. Many services these days are managed by an occupational health nurse, with an occupational physician pro- viding the medical expertise and guidance on policy matters.
In the past, services had an emphasis on the delivery of treatment, so many existing occupational health departments have given considerable space to clinical areas. Although there may still be a need for this, in order to be a part of a service the role of treatment has been reduced significantly and thought needs to be given to how to adapt these areas for the delivery of a more proactive service. It is often necessary to convert these facilities to allow for such activities as health screening and surveillance and provide suitable surroundings for counselling sessions, while ensuring that all members of the occupational health team have adequate office provision to allow them to perform their administrative activities effectively.
The provision of equipment is of course essential, and appropriate screening tools are required, depending on the findings of the assess- ment. Often in a manufacturing environment the need for such items
as sterilising equipment has been superseded by sterilised packs, of- ten used by confident, well-trained first aiders, and specific information technology tools have replaced the need for day sheets.
Information Technology Information technology must be consid- ered as a basic management tool that needs to be used by occupational health services, although there has been nervousness from the medico- legal profession about moving away from hard-copy medical records.
Information technology assists the service in producing effective statis- tics for the monitoring of trends in the health status throughout the or- ganisation, along with achieving a better understanding of the costs and benefits of delivering the service. This provides valuable information to ensure that the service remains focused on the important issues and is able to talk convincingly to management about them. In addition, e-mail has become a basic tool for communication and it is important that all OH personnel have individual e-mail addresses, along with access to the Internet as a valuable source of reference.
Priorities The assessment has identified a list of needs associated with health issues in respect of health and safety legislation, litigation con- cerns and business objectives. Occupational health can cover such a wide area, with all health issues appearing to be of equal importance, that it is easy to fall into the trap of trying to respond to all the needs as they present themselves. The danger of this, of course, is that nothing is delivered effectively, leaving management confused as to the value of the service that it is receiving.
While acknowledging the extent of the issues that need to be ad- dressed, it is now necessary to prioritise according to the importance of the impact each will have on the organisation. This is why it is essential for the occupational health service to understand the business objectives of the organisation, so that it can focus its activities to respond to these and avoid working in isolation from the rest of the company. In order to set the objectives for the service, therefore, the questions that again need to be asked are: Where are we now? Where do we want to be? How do we get there?
Setting Policies and Procedures Once the priorities have been de- cided, policies need to be set for the occupational health service so that the occupational health team, management and workforce are clear on what the service is aiming to achieve. Policies are likely to be set for such areas as fitness-for-work health screening – including pre-employment health assessment; health surveillance – for employees exposed to health hazards; case management of ‘ill’ employees – to provide advice to human resources/line managers on their effective return to work; first aid – to ensure compliance with legislation; counselling – to enable a