Health and the HSE: the first 25 years
This personal perspective from Tim Carter, the senior medical doctor within the HSE from 1982-1996 amplifies the summary given in Chapter 12 (paras. 106-108) of ‘Why Robens?’ by David Ashton.
To look at the health risks and the approaches to health management that confronted HSE before 2000 it is essential to start by visiting events in the years leading up to the Robens report. In the 1960s there were several medical and health related activities associated with the Department of Employment. The Factory Inspectorate had a small number of medical inspectors, whose focus was on a limited range of clearly work-related diseases, in particular industrial poisonings and chest diseases. The inspectorate also oversaw a large part-time contingent of Appointed Factory Doctors, mainly GPs, who performed medical examinations on young persons entering industry and who undertook statutory medical examinations on workers exposed to a specified list of diseases. There were also part time doctors and full-time nurses who supported the Manpower Services Commission (MSC) Employment Rehabilitation and Skill Centres.
The then senior medical inspector, Dr Trevor Lloyd Davies took a critical look at these arrangements, including widespread consultations and surveys, concluding that some aspects of service delivery were far from ideal or indeed useful. He secured major reforms with the passing of the Employment Medical Service (EMAS) Act in 1972. This created a service with a responsibility to advise generally on health and work as well as supporting the Factory Inspectorate and employment rehabilitation services. This was to be staffed by a cadre of around 100 full time trained doctors and nurses. It had supporting laboratory provision and concurrently with its creation was embarking on a series of major epidemiological studies on at-risk groups such as asbestos and foundry workers.
The Robens report took a limited view of occupational health, much in line with the duties of the inspectorates and proposed that EMAS form part of the new Health and Safety Executive that was the centrepiece of the report’s recommendations. This limited view differed from the perceptions of most health professionals working within the larger companies and nationalised industries as well as most of those recruited to EMAS. They saw the topic as encompassing continuing medical advice to management and support to help staff with health problems maintain their employment. These aims were aligned with the welfare and wellbeing themes which had developed over the last century either as a matter of corporate altruism or expediency. They were not however shared by many smaller companies or those less concerned with their public image. In addition, many trade unionists were suspicious of the health professions’ orientation towards managerial concerns. The bodies representing this wider view of occupational health were sceptical about the limited role of EMAS as given in the 1972 Act but could see it as broadly aligned with what they saw as good professional practice. They were even more critical of the recommendations of the Robens report and the narrowing of goals that this implied. This seemed surprising given that Lord Robens came from the National Coal Board, which had not only well-developed occupational health provision but also active research programmes on health and elaborate miners’ rehabilitation and welfare services.
The implementation of the Health and Safety at Work Act 1974 started when EMAS was little more than a year old and simply incorporated most of the text of the EMAS Act at Part 2 of the new Act. EMAS had been envisaged as an autonomous advisory service but with this amalgamation it became part of a bigger organisation that also had enforcement powers. It also had a set of responsibilities for the assessment of the effects of illness and injury on peoples’ potential for rehabilitation and training that were distant from the health and safety risk management approaches of HSE.
The newly formed HSE had a number of new or amplified challenges on health risks. The widespread long-term harm from asbestos was becoming ever more apparent, the specific carcinogenic effects of vinyl chloride were recognised and studies clearly indicated the relationship between measured levels of noise exposure and hearing loss. Meanwhile the management of EMAS as part of HSE underwent several changes. Trevor Lloyd Davies resigned after a rear-guard action to defend the autonomy of EMAS, Suzette Gauvain, recruited to lead the training of medical and nursing staff who acted up after his resignation, suffered a fatal illness and stability only came with the appointment of Dr Ken Duncan, previously the Chief Medical Officer of the Atomic Energy Authority, as HSE Director of Medical Services (DMS)
The DMS became a member of the Management Board of HSE and budgetary and personnel management for medical staff was brought within the overall, and at times, competing frameworks of the Executive. The Executive recognised the need to strengthen its skills in toxicology and epidemiology but did not feel any strong obligation to the general advisory duties of EMAS or to its role in employment rehabilitation. Staff resources were diverted to meet the Executive’s agenda, a move that was not popular with clinical staff in EMAS. At the same time it had to be recognised that their general advisory role was not developing as its founders envisaged, not least because EMAS was seen by many employers as being too close for comfort with inspectorates who had powers to sanction and take enforcement action.
From the perspective of the Executive what became its Medical Division (MD) was fulfilling a range of required activities. It was providing medical advice to the Inspectorates, not just to that for factories but to all the others now under the HSE umbrella, for instance to the offshore Inspectors by managing the medical examination requirements for professional divers working in the high tech and hazardous conditions of the North Sea oil fields. The newly created chemical risks group in HQ, a mix of medical and scientific staff, was supporting the work of the Health and Safety Commission’s (HSC) Advisory Committee on Toxic Substances, which played a key role in specifying precautions and exposure standards. Three other HSC advisory committees were also within MD’s ambit. One on medical and occupational health chaired by the DMS, one on dangerous pathogens which was jointly run with the Department of Health and which had an eminent microbiological chair and one covering the fast developing field of workplace and wider safety aspects of research on genetic modification, again with an expert external chair. The division’s research and laboratory functions were another area of rapid development under the innovative guidance of Dr David Gompertz.
In 1982 I was appointed as DMS, a job I applied for very much at the suggestion of Ken Duncan. Previously I had worked with HSE on a range of issues, mainly relating to chemical safety as I was the senior doctor and manager for health, safety and the environment in BP Chemicals. When I started HSE was being ‘dispersed’ to Merseyside and both those who oversaw the medical staff who were now co-located with HSE inspectors around Great Britain and the medical and toxicological advisers were moving there. This was simple and seamless for the field management team but led to a period of tension for the delivery of chemical and other risk assessments. At the same time the first hints of a reduction in the role of EMAS as the provider of support for the MSC became apparent, with the privatisation of Skill Centres leading to redundancies for their EMAS nursing staff.
Field medical staff, in the original concept of EMAS, would take on responsibility for the various statutory medical examinations performed, such as those for lead, asbestos and ionising radiation workers. This proved to be impractical because of travel times and a new network of appointed doctors was created, with some training provided by HSE medical advisers but also by encouraging appointees to take a basic level course managed by the Faculty of Occupational Medicine and set up with HSE encouragement. Field staff were also engaged in a wide range of investigations into work-related diseases. These included allergic risks to the skin and lungs, the former with support from a dermatologist who worked part time with HSE. Notable investigations included those into asthma risks in workers handling the ‘reactive dyes’ that were developed to give synthetic fabrics permanent colours. Skin problems included those in parsnip and daffodil pickers and from strimming giant hogweed on verges. The diversity of these problems led HSE to fund and support the development of voluntary reporting systems for dermatologists and chest physicians to report suspicions of occupational lung and skin diseases with both known and novel causes. These became a major new source of information on occupational health risks.
Employment Nursing Advisers had gained a major new set of responsibilities with the move from requiring that workplace first aiders were trained by the Red Cross or St John’s and St Andrews Ambulance to a more open system where a wide range of commercial providers entered the market. The Advisers approved course contents and monitored them. The same advisers also played a significant role in linking with the several thousand nurses working within industry and helping them develop their status, while often arbitrating in issues of confidentiality and ethics. The nursing staff and part-time doctors supporting the Employment Rehabilitation Centres went the way of those in the Skill Centres in the late 1980s as these centres were wound down, more because of a political fix, where they had first been required to take in a people with mental health and attitudinal problems to returning to work to reduce unemployment statistics and were then found to be failing to place such people in employment. During this time Dr Felicity Edwards, the senior medical adviser who had coordinated EMAS rehabilitation work took a leading role in producing the first edition of Fitness to Work: the Medical Aspects, a book published by the Faculty of Occupational Medicine and Oxford University Press which is now recognised as the definitive textbook on the subject and is currently in its sixth edition.
Staffing of EMAS was a problem as paying market rates for doctors was a hard pill for the Civil Service to swallow. HSE was fortunate in being able to recruit and train a good number to become registered specialists on occupational medicine. Many trained using the Manchester University distance learning course, which HSE had supported by giving seed-corn funding for its development in return for free places once it was established. The diversity of experience gained in EMAS was valued by trainees as well the knowledge gained in an organisation with an active framework of academic contact and a chance to see and advise in the murkier corners of industry. However, the downside was that few of those trained stayed in HSE as they were in demand for jobs elsewhere. This became more extreme when they could benefit from favourable redundancy terms available to their grades of civil servants and then easily pick up more lucrative jobs in industry or more fulfilling ones in academe.
International work became more prominent, mainly within Europe, but sometimes worldwide. The International Labour Organisation started work on a Convention and Recommendation on Occupational Health Service. Dr Peter Brown represented HSE at a series of meetings in Geneva. Here again the dissonance between the UK position of a limited role for regulation on service provision was at odds with the approach in many other countries where either state or social security funded services were required for either all or selected groups of high-risk industries. HSC opposition to service development in Britain meant that the Convention went unratified, much to the regret of many occupational health professionals. Certain topics called for international understanding; the prominence of concern about neurobehavioral effects attributed to solvents in the Nordic countries led to visits to find out more and it also showed up one of the features of HSE working methods. A medical adviser attending these meeting often had someone from a policy division with them to put forward any concerns about uncritical adoption of the results for studies done elsewhere. In reality what was apparent was that some countries saw distress or psychological test results as sufficient to take action while the UK awaited pathological changes before doing so.
European Directives also had consequences. In some areas HSE had provisions in place in advance of others, for instance for chemicals (COSHH) and on lead and asbestos, these often became a model for others. Other topics that EC members wanted to regulate were anathema to HSE. This was apparent on the precautions needed to safeguard those working on display screens, where HSE had to put in place controls in an area that would not normally have been considered as there were few clear harmful effects and much focus on comfort and on the distress caused by new technology. Developing controls was a challenge for the one psychologist employed within HSE, Colin Mackay. He had a sound research background and went on the lead on other similar topics, such as some internally controversial research on supermarket check-out workstations and later the development of management standards for the control of stress at work.
Many activities were shared endeavours. Some with other parts of HSE, for instance the privatisation of the rail industry created new requirements for standardised medical fitness assessments. Here the use of existing professional qualifications for approval of medical services was adopted. This was not the usual approach of HSE as there was a perceived danger of creating an externally controlled monopoly. The response to the finding of a leukaemia excess in the children of workers at the Sellafield Nuclear Plant led to joint studies with the Nuclear Inspectorate, which had a culture based on licencing establishments and hence to the close involvement of inspectors in every aspect of the risk to workers. Licencing also came to the fore in discussions about risk to agricultural workers who were required to dip sheep at regular intervals and who were concerned about the health effects. The licencing of dips was a matter for the Veterinary Medicines Committee of the Department of Agriculture. Their approach was to post precautions, sometimes unrealistic ones, on the dips and to say that, if followed, these would guarantee safety. The HSE approach was to accept uncertainty about risk and make practical requirements for protective measures.
Interdepartmental work was the norm on emerging infections where HSE was responsible for occupational risk, while public health authorities were concerned about risk to the general population. Again, differences in practice and cultures loomed large in the responses to HIV/AIDS, legionnaires disease and BSE. A joint working group dealt with aspects of legionnaires, while informal liaison between medical scientists, especially David Gompertz and opposite numbers in the Department of Health was critical for the other conditions.
Successive Directors General of HSE were keen to forge a more coherent corporate identity and one that aligned with the division of work into policy, specialist advice and field inspection activities. This led to the effective eclipse of some of the self-identification of staff, for instance as members of EMAS or of particular inspectorates. Changes affecting medical staff included the ending of a separate annual report that could highlight work done and challenges, notable the search to make ‘Good health is good business’ a reality. More significantly I moved from being Director of Medical Services to being head of a new Health Policy Division based in London, while remaining head of profession for medical staff, most of whom where in a Field Operations Division that included all those in the peripheral offices of HSE, while a some, such as epidemiologists, toxicologists and psychologists were brigaded in a specialist services division on Merseyside. This was not ideal for the flow of information and support between medical, scientific and nursing staff under different commands and at different locations. A later move took away the long established and forward-looking biomedical research programme, replacing it with a customer/contractor relationship between HSE divisions and research providers.
The Health Policy Division took over many of the functions of the now disbanded Hazardous Substances Division and I took over the chair of the HSC Advisory Committee on Toxic Substances, which had become a major force in setting exposure limits for the use of chemicals. This process had developed a complex theology of its own in alliance with representatives of major chemical companies. This approach came to a head with the introduction of a numerically more lenient standard for silica, but one that required active steps to be taken to reduce exposure levels below it. This was the beginning of a realisation that new and simpler approaches such as exposure banding were needed, especially for small user companies who lacked the resources of the chemical majors. My successors Alan Brown and Peter Graham took these measures forward in the 1990s.
In 1992 I moved to head the Field Operations Division, with some 2,000 staff in offices around the England, Scotland and Wales. Health Issues became a much smaller part of my work while the training of inspectors became more important. One of the problems for inspectors on health was that the effects of an exposure to risk were often delayed and could, for instance with asthma and skin disease, be relatively non-specific. A solution to this lay in the new format of regulations such as those for asbestos, lead and COSHH, which covered chemicals in general, as well as those concerned with ergonomics, such as manual handling and display screens. All included a requirement for employers to assess risks and then put appropriate control measures in place. Completion of these requirements provided a sound basis for inspectors to assess compliance, while health professional involvement was only really needed when exceptions or unexpected health risks were identified.
For my last year in HSE I undertook two major projects. One to see how the NHS and Department of Health staff could be more actively involved in work related health issues. A report was delivered, but no real progress was made based on it. The other was a project to look at the closer integration of medical and nursing staff into the work of HSE. This resulted in the re-creation of the concept of medical inspectors and the training of doctors and nurses to be able to take on enforcement as well as advisory duties. It could be said that this was the end of the concept of an Employment Medical Advisory Service. Such a service, had it remained autonomous, would almost certainly have disappeared in the in the changing political climate of the 1980s, had it not become part of HSE. Subsequent events, such as the Department of Work and Pensions work on rising levels of absence attributed to illness, in particular stress and musculoskeletal pain and even more the current concerns about return to work after Covid infections show the importance of medical advice within government on the effects of health on availability for work as well as on the remit of HSE that relates to the health risks from work that was progressively lost between 1974 and 1994.
Sources
General
Annual/Biennial reports of DE Medical Services Division, EMAS, HSE Medical Division 1972-1985.
Director of Medical Services Annual Medical Conference Review of the Year 1986-1991.
Formation of EMAS
Gracey M. The Employment Medical Advisory Service. Br J Ind Med 1973; 30: 92-94.
Browne RC. Safety and Health at Work: The Robens Report. Br J Ind Med 1973; 30: 87-91.
Lloyd Davies TA. Whither Occupational Medicine? Proc. Roy Soc Med 1973; 66: 818-822.
Gauvain S. Recent Developments in Occupational Medical Services. J Soc Occ Med 1975; 25: 78-85.
Later reviews of EMAS
Henderson RTS, Carter JT. The Employment Medical Advisory Service. Postgrad Med J 66; 1990: 457-461.
Carter JT. Twenty-one Years of EMAS. Occup Med 1994; 44: 115-122.