Health Surveillance Guidance

Introduction

Health surveillance is about putting in place systematic, regular and appropriate procedures to detect early signs of work-related ill health among employees exposed to certain health risks; keeping individual health records and acting on the results. To comply with the law, this means selecting from a range of specific techniques:

A 'responsible person' looking for a clear reaction where someone is working with something that could harm their health. For example checking for skin damage on hands where solvents are being used, or checking answers on simple, periodic questionnaires about symptoms.
A 'qualified' person asking employees about symptoms of ill health, or inspecting or examining individuals for signs of ill health. Examples might be someone conducting a hearing test, or an occupational health nurse carrying out a lung function test where workers regularly use isocyanate paints.
Medical surveillance by a doctor, which can include clinical examinations, for example to look for a reaction from exposure to some chemicals.
Biological and biological effect monitoring to measure and assess the take-up of, or the effects of, exposure to substances such as lead or other chemicals, by testing blood, urine or breath samples.

Other elements of health surveillance include:

Self-checks by employees to look for and report any signs of work-related ill health. These are an important part of any programme to pick up possible ill health effects. However, self-checks on their own are not sufficient to comply with regulations. They will help you to meet your duties only where they are part of a programme in which health records are kept and where employees are:
- trained about what signs of disease or illness to look for and when and how to do so; and
- told when and how to report any signs or symptoms to a responsible person or occupational health professional;
- also subject to periodic checks by someone else such as a responsible person.
Baseline health assessment, carried out when a person takes up or changes job. This can be considered to be part of health surveillance only where it establishes baseline information that can be compared with the later results from surveillance. Always determine the need for such an assessment, and the way you carry it out, on the basis of its relevance to the job in question.

Giving information to employees and their representatives and referring employees to an occupational health professional where extra checks are needed.

Other health monitoring procedures

There are other things you can do to monitor the health of your employees that should not be confused with health surveillance and so are beyond the scope of this guidance. Some may be legal duties, for example to assess fitness for work; others are not legal duties but can be used for other purposes, for example general annual health checks. The most common of legal duties are:

Pre-placement and annual medical examinations to assess an individual's fitness for work, for example under the Ionising Radiation Regulations or under the Diving at Work Regulations.
Health screening to meet legal requirements, such as making eyesight testing available under the Health and Safety (Display Screen Equipment) Regulations, or an assessment of someone's fitness to drive or operate cranes within dock premises (Docks Regulations).
Fitness for work health assessments offered to night workers under the Working Time Regulations.

(You should also remember that under section 2 of the Health and Safety at Work etc Act 1974 (HSW) you have a general duty to ensure, so far as is reasonably practicable, the health, safety and welfare of all of your employees.)

The most common examples with no legal duty are:

General non-statutory pre-employment health enquiries to check an individual's health status and medical history.
Monitoring sickness absence records. These can be a useful source of intelligence and a means of assessing risk where more formal health surveillance procedures are not appropriate. Looking at collective sickness records could help you identify where there is a general problem affecting workers' health. Individual sickness records might indicate whether work is affecting an individual's health.
Lifestyle health promotion and education to explain the benefits of, for example, enjoying a healthy diet, taking regular exercise, drinking sensibly and stopping smoking. This might be extended to include screening clinics, for example to test cholesterol and blood pressure levels. These activities are usually part of a benefits package, one purpose of which may be to reduce sickness absence.
Annual health checks of key personnel. These can be extended to 'health MOTs' for all employees and may also help to assess the impact of health education at work.
General testing of workers for evidence of drug or alcohol misuse, unless there are specific safety-critical implications.

benefits of health surveillance

The benefits of health surveillance are that it can:

provide information so you can detect harmful health effects at an early stage, thereby protecting employees and confirming whether they are still fit to do their jobs;
check that control measures are working well by giving feedback on risk assessments, suggesting where further action might be needed and what it might be,
provide data, by means of the health records, to detect and evaluate health risks,
provide an opportunity to train and instruct employees further in safe and healthy working practices, for example how to use personal protective equipment (PPE) properly, and
give employees the chance to raise any concerns about the effect of their work on their health.

When is health surveillance appropriate?

Don't think of health surveillance in isolation; it is one part of the overall management of health risks. Before introducing health surveillance:

find out what the health hazards are where you work;
identify those employees who might be at risk from being exposed to hazards;
decide what to do to make sure your employees' health is not harmed. To do this, try to get rid of the risk altogether. Where this cannot be done, see whether the risk can be reduced or controlled to such a level that it will not be harmful to health. This will not always be possible, so you will need to take further steps, such as providing PPE and introducing health surveillance.

Health surveillance is required where you answer 'yes' to all the following:

Is the work known to damage health in some particular way?
Are there valid ways to detect the disease or condition? Health surveillance is only worthwhile where it can reliably show that damage to health is starting to happen or becoming likely. A technique is only useful if it provides accurate results, is safe and practical,
Is it reasonably likely that damage to health may occur under the particular conditions at work?
Is surveillance likely to benefit the employee?

Assessing the need for health surveillance

When assessing whether health surveillance might be appropriate include:

if you know of previous cases of work-related ill health in your workplace;
where you rely on PPE, for example gloves or respirators, as an exposure control measure. Even with the closest supervision, there is no guarantee that PPE will be effective at all times;
where there is evidence of ill health in jobs found in your industry. Such information could come from insurance claims, manufacturers' and suppliers' data, HSE and other guidance and from industry experience.

Ask yourself whether any of your employees are exposed to the following:

Hazardous substances such as chemicals, solvents, fumes, dusts, gases and vapours, aerosols, biological agents (micro-organisms). If so, health surveillance may be needed under the Control of Substances Hazardous to Health Regulations.
Asbestos, lead, work in compressed air. If so, medical examinations may be needed under specific regulations.
Noise, band-arm vibration. If so, health surveillance may be needed under the Management of Health and Safety at Work Regulations.
Manual handling, work that might give rise to stress-related diseases, work-related upper limb disorders, whole body vibration, hot and cold working, non-ionising electromagnetic radiation. The duty to provide health surveillance is unlikely to apply at present. This is primarily because valid ways to detect ill health conditions associated with these hazards do not exist and/or the link between the work activity and the ill health effect is uncertain. Nevertheless, use other procedures, for example symptom reporting by employees and checking sickness absence records, to ensure that you pick up possible ill health among your employees as early as possible so you can meet your duties under the HSW Act.

Health surveillance is not required where you are sure that there is no exposure or where the exposures that do take place are so rare, short and slight that there is only minimal risk of the employee being harmed. However, some substances can cause very serious illness such as cancers and for these there is often no level of exposure that can he regarded as completely safe. In these cases, health surveillance will almost always be required but may be limited to keeping health records.

In assessing the need for health surveillance, remember that:

health surveillance is not a substitute for preventing or controlling harmful exposure to hazards, but a further way of seeking to protect employees' health;
using the right technique, in the right way, at the right time is important. Getting it wrong can be expensive. Also bear in mind that some tests in themselves are not free from risk (e.g. X-rays) and the results, if inaccurate or not explained properly, could make employees worry unnecessarily;
whichever technique is used, you should carry out health surveillance systematically and regularly; and
simply carrying out health surveillance procedures is not enough; it is essential that you act on the results.

INVOLVING EMPLOYEES AND THEIR REPRESENTATIVES

It is important that employees and their representatives are involved early on to ease fears and to build trust. Employees need to understand their role and responsibility in the health surveillance programme. They need to be sure there are safeguards to protect their jobs if evidence of ill health is found. They need to be asked for their consent to certain health surveillance procedures and be sure that medical information is treated in confidence. Involve safety representatives as they can often be a source of useful, common sense advice about how best to manage change to workplace practices.

Introducing the right programme

You may well need to seek the advice of an occupational health professional to help you decide which type of health surveillance programme would best suit your needs. You may have to use a variety of different techniques, depending on the type and range of working practices and processes. The health professional will be able to help tailor your requirements to the type of business you run. However, this does not necessarily mean that doctors have to be directly involved in carrying out procedures; their role may often be more supervisory or to give advice.

WHO CAN CARRY OUT HEALTH SURVEILLANCE?

The duty to provide health surveillance under health and safety law rests with the employer, so you should therefore seek suitable outside help if there is none available within your firm. It is essential that people who carry out health surveillance are competent to do so. The level of competence depends on the tasks they have to perform. Choose someone who understands the aims of health surveillance and its procedures, who can advise you on the significance of the results and on how and when referral to a specialist might be necessary. Make sure that you are clear about what you expect from your adviser and what you can offer in return.

A responsible person can be trained to make basic checks such as skin inspections for signs of rashes and could, for example be a supervisor, employee representative or first aider. for slightly more complicated assessments, an occupational health nurse can ask about symptoms or carry out an examination. For certain hazards, clinical examinations may need to be carried out by a doctor, preferably one trained in occupational medicine.

FREQUENCY AND LENGTH OF HEALTH SURVEILLANCE

Once you have decided to introduce health surveillance, continue it for at least as long as the individual is exposed to the risk. Increase the frequency of checks or examinations in borderline cases where it is not certain whether exposure might be causing harm. On the other hand, where it is clear that the risk has declined to a very low level, for example because of changing working practices or the introduction of new technology, you may relax the frequency of surveillance. In some cases, the health surveillance programme could be discontinued. Ask an occupational health professional for advice on this if you are in doubt.

Some regulations, for example those governing certain chemicals, lead or work in compressed air; expressly state the interval between examinations. Some also require employers to continue surveillance of people while still employed by them after exposure to the risk has stopped, to detect long-term disease, such as cancer, at an early stage.

Acting on the results OF HEALTH SURVEILLANCE

The real value from health surveillance will only be seen if you take appropriate action in response to the results and then check whether what you have done has worked. Where health surveillance shows that an employee's health is being affected by their work, take the following steps:

Prevent further harm to the individual by reducing, or temporarily removing them from, exposure to the hazard. It may also be necessary to arrange for referral of the individual for further examination and/or treatment by a doctor with expertise in occupational health. Individuals shown to be particularly susceptible to illness or whose health has already been damaged, may need special protection.
Re-examine your risk assessment to decide whether to take action to protect the rest of the workforce or to extend surveillance.
Improve control measures if necessary, seeking the advice of specialists, for example occupational hygienists, as appropriate.

The results of health surveillance should be assessed by the person in charge of the programme. The results can be used in two ways.

First, individual assessments should aim to improve the protection of the employees covered. You can achieve this by making sure that the person who conducts the health surveillance explains the significance of the results to the employee. This would include:

explaining the state of the individual's health in relation to the health risk being tested for;
discussing the correct use of PPE and the importance of using other control measures properly; explaining what happens next if any abnormality is detected; and
stressing that individual medical details will not be released without the worker's written consent.

Second, by receiving an analysis of the health of groups of employees, you can gain an insight into how well your health risk control programme is working. Use the analysis to target your reduction, education and compliance practices more accurately. Such information should be suitably adapted to protect individuals' identities and be made available to safety or employee representatives.

Health SURVEILLANCE records

Health surveillance programmes should include keeping a health record for each individual. These are important because they provide-

an historical record of jobs involving exposure to substances or processes requiring health surveillance;

a record of the outcome of previous health surveillance procedures (in terms of fitness for work, restrictions required etc); and

information for HSE or local authority inspectors to show that health surveillance has been carried out.

Ensure that health records are completed routinely and systematically whenever individuals undergo health surveillance. A health record can be paper-based or held on computer and, as a minimum, should contain:

surname
forenames
Sex
date of Birth
permanent Address
N.I Number
date started present job
an historical record of jobs involving exposure to hazards for which health surveillance is required during the current spell of employment;
conclusions of health surveillance procedures and the date on which and by whom they were carried out. The conclusions should indicate whether the individual is fit to continue to work, including, where appropriate, the decisions of the doctor or nurse where medical assessments have taken place (but not clinical information), or the conclusions of other suitably qualified or responsible people.

Health records are different from clinical records in that they do not contain confidential clinical details and can therefore be kept securely with other confidential personnel records. Records which include medical information arising from clinical examination are held in confidence by the doctor, nurse or other occupational health professional and can only be released to you or anyone else with the written consent of the individual. The Access to Health Records Act allow employees a right to see and comment on their records.

Length of retention of health records

As a general rule, keep individual health records for those employees for as long as they are under health surveillance. Some regulations - COSHH and those for lead, asbestos, ionising radiation and compressed air - state that records should be retained for much longer (up to 50 years) as ill health effects might not emerge until a long time after exposure.

It is also good practice to offer individual employees a copy of their health records when they leave your employment. Employers about to cease to trade are obliged under COSHH to notify HSE and to offer to provide paper copies of employees' health records for safe keeping (the same action is recommended in guidance to the Control of Lead at Work Regulations).

Suitable facilities FOR CARRYING OUT HEALTH SURVEILLANCE

Where health surveillance involves inspections, examinations, taking samples and making enquiries, make sure that there is adequate privacy for these to be carried out. Rooms should be clean, warm, airy and have suitable washing, lighting and (separate) toilet facilities.

RIDDOR reporting

Certain cases of disease are reportable to HSE or local authorities. These are listed in a Schedule to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. Some examples are occupational skin diseases; occupational asthma; and certain infections, occupational cancers and musculoskeletal disorders. The duty comes into effect where you receive a written statement from a registered medical practitioner (for example the employee's GP) stating that an employee suffers from one of the diseases and where the employee is currently doing a job involving a specific activity (also listed in the Schedule). Such statements can also act as a useful trigger for you to review how you manage health risks in your workplace.