Health relationships report
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Workforce health and wellbeing project
Health relationships report
Executive summary
The purpose of this report is to provoke industry discussion and
to provide information to improve the working relationships
between rail companies and their health providers. The report
studies the relationships between health commissioners and
health providers and identifies examples of good practice. It
makes a number of recommendations around four key themes for
managing occupational health relationships before drawing
conclusions on the report's findings.
Key theme 1 Contribution of
senior clinical and
OH leadership to the
railway
There is no common source of senior specialised clinical advice
or leadership within the industry. Health practitioners' day-to-day
activities are directed toward meeting the contractual
requirements in individual organisations and there is no forum for
senior health advisors to focus on strategic decisions. Therefore,
industry needs to consider how clinical leadership and senior
specialised occupational health advice across the industry can be
fostered.
New industry leadership approaches could enable health
practitioners to tap into advances in clinical practice and health
technology. An awareness and understanding of developments in
health technology and clinical practice could bring benefits to the
rail industry and drive down costs. RSSB and others should work
with industry leaders, sponsors and partners to support clinical
practice.
Key theme 2 - The
market for railway OH
provision
A restricted choice faces rail organisations looking to outsource or
re-tender their OH service. Barriers include Link-up accreditation
for providers and the distribution of the rail network. Railway
organisations need to consider how to facilitate a broader
approach to tendering for their occupational health service, so as
to ensure that they have sufficient choice and can take advantage
of advances in occupational health practice.
Key theme 3 Organisational
approaches to health
management
Health commissioners in individual rail organisations should look
to improve their commissioning arrangements to ensure:
 The purchase of a quantum of senior strategic health input
 That clinical leadership is held to account for health policy
at the very top of the organisation
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Health relationships report
 That services are commissioned to a broader range of
interests within railway organisations.
Internal organisational arrangements also need to be addressed
as there appears to be a poor understanding of the role of
occupational health amongst frontline managers, and how to get
the best value for money from occupational health professionals
and providers.
Guidance on provider engagement in the industry may assist with
these issues.
ii
Key theme 4 - Quality
assurance and health
relationships
Health practitioners, especially those working in remote locations
or as network physicians, have difficulty in gaining workplace
experience in the industry, or obtaining information about it. New
and aspirant entrants to the railway industry also struggle to get
rapidly up to speed in their knowledge of the industry. The
industry needs to consider how it can improve this, so that a wider
range of qualified and experienced practitioners are available to
the industry. RSSB should work with senior professionals in the
industry and the Association of Railway Industry Occupational
Health Practitioners (ARIOPS) to develop a suite of supporting
information to enable a quality service.
Conclusion
The railway industry needs to consider its commitment to all of the
dimensions of occupational health as set out in the Office of Rail
Regulation (ORR) health programme 2010 to 2014. In particular
it needs to consider how it can address the challenge of
expanding the focus of occupational health to address the
adverse effects of work on health and to broaden the approach to
wellbeing. A high-profile industry driven initiative similar to the
Boorman report process used in the NHS, or Constructing Better
Health (CBH) may achieve a sea-change in attitudes and
commissioning, especially if tied to government initiatives such as
the Public Health Responsibility Deal and was backed by the
Department for Transport. A national initiative of this sort will have
a short term impact on all organisations but avoid competitive
disadvantage and on-going uncertainty as to how to manage
health risk.
RSSB
Table of Contents
Health relationships report
Executive summary.............................................................................................................i
Key theme 1 -Contribution of senior clinical and OH leadership to the railway ................i
Key theme 2 - The market for railway OH provision .........................................................i
Key theme 3 - Organisational approaches to health management ..................................i
Key theme 4 - Quality assurance and health relationships ............................................. ii
Conclusion..........................................................................................................................ii
Introduction to the Health relationships report...............................................................1
What we mean by 'health'................................................................................................1
Encouraging a culture of excellence in the management of health .................................1
Method.................................................................................................................................2
Survey of OH providers ...................................................................................................2
Survey of OH purchasers ................................................................................................2
Study of comparator organisations ..................................................................................2
Study of the implementation of T663...............................................................................3
Stakeholder views ...........................................................................................................3
The project steering group...............................................................................................3
Contribution of senior clinical and OH leadership to the railway..................................3
Early health relationships in the rail industry ...................................................................3
Occupational health practice before privatisation ............................................................4
Occupational health practice following privatisation ........................................................5
Leadership.......................................................................................................................5
Educational support for railway medicine ........................................................................6
The market for railway OH provision................................................................................7
Responses to restricted OH market ................................................................................8
Wider consequences of restricted OH market .................................................................8
Organisational approaches to health management......................................................10
Tendered outsource ......................................................................................................10
In-house service ............................................................................................................10
Service level agreement/partial in-house ......................................................................11
Health relationships around the response to T663 ........................................................11
Who commissions OH services? ...................................................................................12
Communications and health relationships .....................................................................14
Quality assurance and health relationships ..................................................................16
Qualifications of practitioners ........................................................................................16
Experience, expertise and health relationships .............................................................17
Conclusion........................................................................................................................19
Achieving transformational change in rail health relationships ......................................19
Introduction to the
Health relationships
report
The purpose of this report is to provide information to improve
working relationships between rail companies and their health
providers. More proactive health management activities with
health providers will create improved business benefits for the rail
company through more knowledgeable client's contractual
requirements. The business benefits gained through healthy staff
will be maximised through better health provider contracts. The
report studies relationships between health commissioners and
health providers to aid the identification of available good
practice.
What we mean by
'health'
Health, as considered in this report, refers to health as
categorised by the ORR's occupational health programme 20102014, under three areas:
 The effect of work on health, including for example, the
adverse effects of exposure to dust, asbestos, noise,
vibration or the causes of musculoskeletal disorders
(MSDs) or work-related stress.
 Fitness for work including people's fitness for safety critical
tasks and covering for example, drugs and alcohol
management, and periodic health assessments.
 General wellbeing, including health and life-style, sickness
absence management and rehabilitation. This includes
adjustments to the working environment to support people
with certain conditions to work effectively, and the
rehabilitation of people who have suffered health disorders.
Encouraging a
culture of excellence
in the management of
health
In its occupational health programme, ORR seeks to stimulate
investment in competent health assistance for managers,
enabling them to comply with laws aimed at preventing the ill
health of employees, as distinct from merely employing
professionals to undertake fitness assessments or to provide
counselling. Such professionals would support managers in
dealing with the effect of work on health and would be an
'intelligent customer' for contracted health services, such as
medical fitness.
ORR expects organisations to manage health to at least the
minimum standard set by law and would regard an excellent
organisation as one that delivers compliance with these laws
efficiently, and seeks to go beyond the law by investing in
rehabilitation and wellbeing amongst other things. ORR makes it
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clear that it will enforce compliance where necessary, and
highlights work issues affecting health including musculoskeletal
disorders, stress, hand arm and whole body vibration, noise,
substances hazardous to health (including diesel exhaust), lead,
asbestos, and microbes. It also highlights obesity, cardiovascular
disease, back pain, fatigue and sleep disorders as health issues
impacting on wellbeing, life-style and attendance at work.
The present study seeks to evaluate health relationships to
uncover and propose good practice to support the development
of a culture of excellence in occupational health.
2
Method
The study was undertaken by means of a series of semistructured telephone interviews by the contracted health
specialist, with key personnel within and outside the railway
industry. Organisations were chosen to reflect existing
experience in commissioning and providing occupational health
to the industry, and also to elicit the views of key stakeholders in
the industry. The study also sampled the delivery of occupational
health services outside the railway industry.
Survey of OH
providers
A range of occupational health providers were surveyed including:
Survey of OH
purchasers
A range of railway organisations were surveyed, including the
Infrastructure maintainer, a not-for-profit organisation, together
with an independent commercial infrastructure provider, a freight
operating company and a variety of train operating companies.
Companies were chosen to reflect both the perspective of longterm franchise holders, and that of organisations where the
franchise is close to expiry.
Study of comparator
organisations
Two comparator organisations were studied. One was a large
national organisation with personnel distributed throughout the
United Kingdom. The other was the NHS; as a large but devolved
national organisation, it is reflective of the diversity of
occupational health challenges but with a closed culture similar to
that of the railway family, and facing a franchised future rather
similar to the railway industry.
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



Large national organisations
Smaller organisations, sometimes acting as subcontractors
New entrants to the field of railway occupational health
Aspirant companies that wish to provide a service but who
have so far been unable to acquire business within the
sector
 An in-house provider
Study of the
implementation of
T663
Participants were questioned regarding their awareness of, and
any practical steps which they had taken to implement, the RSSB
report 'Managing the risk associated with sudden incapacity in
safety critical occupations' (T663) as a means of evaluating the
scope of their health relationships around the handling of a
complex piece of research.
Stakeholder views
A workshop was held to obtain the views and opinions of the
railway trade unions that work across the whole industry, and
have a long corporate memory. This was complemented by
interviews with two long-standing railway physicians whose
experience reflects back before privatisation and both within the
main provider since privatisation, and outside this organisation in
a governance role within the industry.
The project steering
group
The project was overseen by a steering group made up of senior
representatives from within the rail industry.
Contribution of
senior clinical and
OH leadership to the
railway
There is no structure for a common source of senior specialised
clinical advice or leadership at the industry level, nor is there a
supportive structure for physicians to provide mentoring or to
enhance knowledge of railway medicine. Health practitioners'
day-to-day activities are directed toward meeting the contractual
requirements in individual organisations and there is no forum for
senior health advisors to focus on strategic decisions. This part of
the report discusses the background to the current situation, and
offers suggestions to address these omissions.
Early health
relationships in the
rail industry
The association between railways and health care services began
following the opening of the Liverpool and Manchester Railway, in
1830, and as the railways rapidly grew in Britain medical services
became an early feature. This was especially because the
development of railways involved ambitious engineering and
construction work on a scale and at a rate previously unknown,
and which had tragic consequences in terms of injury and death
to construction workers, operating staff and even passengers.
The object of early railway medical services was thus very much
focused on treatment to maintain and to restore health, especially
after serious accidents, in a workforce which was comparatively
well paid but dispersed geographically and away from the
traditional centres of medical support in towns and cities.
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Gradually in the 20th century, railway medical personnel
relinquished their treating roles, as public health services
developed, culminating in the establishment of the National
Health Service in 1948. The railway medical service then focused
on health and work, now known as occupational health.
Occupational health
practice before
privatisation
The British Rail Occupational Health Service (BROHS) was
established following the nationalisation of the UK's railways in
1948, by the amalgamation of the medical services provided by
the predecessor companies. The BROHS was a centralised
institution organised on regional lines, with occupational health
centres situated in most large cities and railways centres, such as
Crewe and York. Each centre had its own medical officer who was
supported by nurses and administrative staff, and who undertook
responsibility for carrying out pre-employment, periodical and
management review medicals in the geographical area
surrounding the centre. At this time there was no strong tradition
of involvement in health surveillance or wellbeing, as this was in
the early days of the Health and Safety at Work Act, and before
its more detailed regulations became effective.
Railway physicians were trained in the occupational health of the
railway by an apprenticeship system, without formalised
specialist training. The remit of railway doctors and nurses
extended beyond the operation of railways, to hotels and
specialised engineering works. Familiar with the environment of
the integrated railway, the medical staff would see track workers,
signallers, station personnel and train operating crews without
any distinction as to their employing organisation.
The medical service in this era was directed by a chief medical
officer who was accountable to the British Railways Board (BRB).
Some of today's concepts of modern railway occupational health,
for example the adverse effects of hazardous health issues, or
broader consideration of wellbeing, would have been raised by
top-down action from the BRB, or by input to the BRB from their
medical officers, who met quarterly to compare notes and practice
and to discuss medical developments. This structure provided
mentorship for new entrants to the field and also created a cadre
of senior physicians who provided a body of expertise and clinical
leadership to the industry's health function.
Medical officers' meetings led to the development and on-going
maintenance of the BR railway medical officer's handbook. This
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was before the 'clinical effectiveness initiative' transformed
medical and health practice; so the informal, non-referenced,
consensus-based guidance that it contained was comparable to
NHS documents of the time.
Occupational health
practice following
privatisation
After privatisation, the railway occupational health service was
initially floated as an independent company. In the late 1990s,
BUPA obtained the service in its entirety. This included the rights
to use the existing medical centres at major stations and railway
centres and exclusive access to the former BR railway medical
officers' handbook. This handbook was regarded by BUPA as
'commercial in confidence', thus later entrants to the railway
occupational health have been denied access to the document.
More recently, the new providers of railway OH have built their
railway medical structure from scratch, recruiting experienced
railway physicians from other providers, or from other railway
organisations such as London Underground. Individual
occupational health physicians have relied on their understanding
of occupational health as practised in other comparator
industries, such as road transport or civil aviation. Many of these
new entrants have a limited amount of high-quality medical
information made available to them by the codes of practice
associated with the railway group standards. Some may hold
personal copies of the old BR railway medical officer's handbook,
but this is now out of date.
Leadership
Whilst fragmentation of the formally comprehensive and universal
occupational health service has led to the loss of continuity, both
geographically and in time, it has allowed new providers to bring
in some new ideas, and to trial innovative approaches from
comparator industries. However, many within the industry and its
occupational health providers, remain concerned about the loss
of continuity and expertise associated with the experience of the
former BROHS. As a result, former railway occupational health
physicians formed a small voluntary professional association,
which for the most recent five years of its existence has been
multi-disciplinary, including nurses and allied healthcare
professionals and is now called the Association of Railway
Industry Occupational Health Practitioners (ARIOPS). As a
voluntary body, ARIOPS has struggled to maintain its role,
although it is evident, from the many references to it in official
documents, that others in the industry recognise the need for an
institution which focusses professional clinical leadership.
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Summary 1
Prior to privatisation, the BROHS provided a continuous source of
senior specialised advice within the industry and clinical
leadership throughout it, which competitive structures
subsequent to privatisation have not been able to replicate.
Recommendation 1
Industry needs to consider how clinical leadership and senior
specialised occupational health advice across the industry can be
fostered. This may differ in its priorities from the day- to-day
interests of occupational health contractors, but should help rail
organisations to focus on strategic issues such as the adverse
effects of work on health and the need to develop broader
approaches to wellbeing as set out by the ORR.
Educational support
for railway medicine
Within railway occupational medicine, there is no longer a
supportive structure for physicians to provide mentoring or to
enhance knowledge of railway medicine. Experienced
practitioners may move into and out of the industry as frequently
as contracts change. The contrast with aviation medicine could
not be greater, for aviation medicine enjoys the support of a
bespoke examination and specialist field, and is backed by
research funding, appropriate academic support and the RAF. By
contrast in the UK, academic and research support for railway
medicine is almost non-existent, which means that there is no
infrastructure to enable benchmarking or evaluation of the
effectiveness of existing services or their focus.
Case study: A large comparator organisation runs an annual
conference to which all of its occupational health practitioners are
obliged to send all of their occupational health staff. The
conference is provided by the sponsoring organisation but the
contractors are expected to release their staff. At this conference,
OH professionals are brought together with health and safety and
operational and human resource managers and the focus is on
company strategy and what the company wants from their
providers.
Summary 2
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In a competitively tendered 'revolving doors' occupational health
environment, support of the educational and academic
development of the subspecialty of railway medicine within
occupational health is difficult. However, it is essential, so as to
make sure that industry gains the maximum advantage from
changes in clinical practice and health technology.
Recommendation 2
RSSB and others should work with industry leaders, sponsors
and partners to provide meetings and educational material to
support railway occupational health. An example might include
sponsorship of a national railway occupational health event to
which health commissioners and health providers should be
invited or even mandated to attend by sponsoring rail
organisations. The excellent conferences and interactive web
forum maintained by ALAMA (the Association of Local Authority
Medical Advisers) would form a good example, although much
larger in scale than anything that the rail industry could sustain
though ARIOPS, the comparator organisation.
The market for
railway OH provision
The number of organisations providing occupational health to the
railway industry is slowly growing, as the initial provider loses its
monopoly influence. A number of customers have sought
alternative providers, regarding existing products as insufficiently
flexible and responsive to the needs of the industry, particularly as
the turnover of TOC franchises brings new ideas and new
approaches to management. Despite reluctance due to the
logistics involved, they have sought to transfer their service
elsewhere but within the rail industry this is not simple.
Responses to
restricted OH market
Two large rail businesses strongly expressed their frustration at
the limited choice of provider in commissioning a service
throughout the UK, and this difficulty was also apparent in non-rail
purchasers with similar needs. One national organisation had got
around this difficulty by commissioning from more than one
provider. It recognised that only a small localised OH company
could provide the bespoke service which it required for a specific
site, but the more generic product available from a large national
provider was more reliable in dispersed circumstances. Another
large (non-rail) business which was generally characterised by a
strongly strategic approach to OH had responded to this
challenge by building a small in-house team.
Wider consequences
of restricted OH
market
The restricted access to the railway occupational health market
means that some opportunities for health processes and
techniques, which could be of assistance to the industry in
managing absence, such as occupational health linked case
management, have not materialised. In other cases, a traditional
and transactional approach to commissioning and contract
management has resulted in the failure make use of senior
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clinical personnel to offer strategic advice. This advice could
enable things to be done better or more effectively and develop
clinical leadership.
Case study: an occupational health provider which was not
contracted to undertake any railway work, but which would like to
get involved, has developed expertise in case management
linked to occupational health. As a result, it had managed to
reduce sickness absence in an organisation from 6.9% to 4.1%.
Summary 3
Providers and purchasers agreed that there was a restricted
choice facing rail organisations looking to outsource or re-tender
their OH service. This is especially so for purchasers whose
businesses are spread widely throughout the UK. This restriction
is true for all nationwide organisations, but the special conditions
of the rail industry make it even more challenging. The restricted
occupational health market also prevents the rail industry from
gaining access to some of the more innovative approaches to
occupational health provided by outside providers.
Recommendation 3
Railway organisations need to consider how to facilitate a broader
approach to tendering for their occupational health service, so as
to ensure that they have sufficient choice and can take advantage
of advances in occupational health practice.
Broader approaches might include contracting with more than
one organisation to ensure national coverage, or else to gain
especial expertise.
The need to acquire experience and expertise in the particular
requirements of the industry appears to have acted as a barrier to
new providers to enter the field, especially as the necessary
experience and expertise has to be sufficient to meet such
requirements as Link-up audit and accreditation.
Case study: when the Safe Effective Quality Occupational Health
Service (SEQOHS) system of accreditation for occupational
health services was developing, NHS occupational health
services felt under some pressure to be in the forefront of this
initiative. However the scheme as set out did not include all of the
specialised areas relevant to NHS occupational health practice.
So it was agreed that the NHS would work with the Faculty of
Occupational Medicine, the sponsor of the scheme, to develop
health specific domains within the main scheme.
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A further barrier to entry to the railway occupational health market
exists in the requirement to provide clinics close to railway
centres, often located in the centre of cities and distanced from
the more provincial industrial or NHS locations of many
occupational health providers.
Case study: one occupational health provider with considerable
experience in railway occupational health commented that they
had turned down additional national railway work because of the
requirement to provide clinics within walking distance of railway
centres. They had worked out that this was not viable unless the
work continued for at least two years, and in this case contract
was for no more than nine months. Another provider who is
outside the railway occupational health field at present, but would
like to participate, remarked that they had so far not tendered for
railway work because of the requirements for Link-up
accreditation and the obligation to provide additional clinic
premises near to rail centres in major cities.
Summary 4
Recommendation 4
There are two main barriers to creating a wider market in
occupational health, these being the need to meet the specific
standards in Link-up accreditation and to provide clinics facilities
in each and every railway centre.
1 Opening up the accreditation scheme by integrating Link-up
into a railway specific domain of SEQOHS (as with NHS
occupational health services), should lead to a significant
widening of the occupational health provider market
2 Further measures to expand this market might include
looking to provide clinic facilities available to rent in railway
centres by landlords such as Network Rail, as occurs with
other railway related services
3 The rail industry could arrange frameworks to guide OH
provider expertise as highlighted in Summary point 2
Organisational
approaches to health
management
There are three business models used to provide an occupational
health service. The commonest model is the tendered outsource.
Tendered outsource
In this model, health relationships are focused on measurable
outputs such as KPIs, rather than on higher level outcomes.
Clinicians complain that they have no strategic input into the
contracts, which may be of short duration. Meetings, when they
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take place, in are 'set pieces' between contract managers and
rarely involve clinicians. There is a lot of frustration amongst
clinicians who feel that their high-level clinical expertise is not
being asked for or used, and generally felt like being 'doc in a box'
who was taken out for a specific purpose and then put back in the
box. Clinicians also describe difficulties in getting close to the
business, such as not having access to the company intranet, so
they cannot directly access company health and safety policies or
business directories. In some cases they are too far removed to
be able to request or arrange site visits to familiarise themselves
with rail environments.
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In-house service
The least common model is one of in-house provision. In this
nurse-managed model, clinical meetings and case conferences
are a strong feature, and the involvement of clinicians is much
more strategic and is integrated closely with the business. The
approach to clinical advice to managers and the business moves
beyond the transactional and becomes educational and outcomefocussed. Clinicians are part of the staff of the rail organisation,
have access to the company intranet and business directory and
access to a driver's cab, to enable them to get close to the
working environment. Senior clinicians, including physicians, are
available to the business to give strategic advice if required and
have been used to help other rail businesses in the same group
to manage their outsource requirements.
Service level
agreement/partial inhouse
This model lies between the two models described above, where
the relationship is set out in a service level agreement, and
depending on the relationship between the customer's
representatives and the clinicians, a greater degree of close
working is possible than with the total outsource. In this model,
clinicians described moving from formalised relationships based
entirely around KPIs, towards a collaborative approach, based on
mutual respect. Clinicians working in this model described the
need for them to work hard on relationships with managers, trade
unions, safety personnel and human resource officers to gain
acceptance, so that their influence can move from the
transactional to the transformational.
Health relationships
around the response
to T663
Research Project T663 - 'Managing the risk associated with
sudden incapacity in safety critical occupations' is a complex and
innovative piece of research which was published in 2009. This
work is one of a number of studies which have been undertaken
to help occupational health practitioners and safety professionals
to understand some of the health dilemmas faced within the
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industry. The project studies the consequences of health risk, and
some of its conclusions are quite challenging, but if applied
throughout the industry could lead to considerable economy in the
interpretation of fitness for safety critical work. However, there is
no evidence that the findings of this research have been applied
anywhere in the industry, whatever the business model.
Implementing this work would require considerable OH
knowledge and expertise within rail organisations and close cooperation between risk and safety managers and senior OH
clinicians. In fact it is difficult to conceive of any railway
organisation being capable of implementing and operationalizing
the consequences and finding of this study, without having its own
company medical officer for reference.
Case study: one large national organisation, which outsources
its occupational health to a number of contractors, also employs
a senior chief medical officer to coordinate health activities
throughout the organisation. This physician reports to and has a
place on the company's board and is able to ensure that health
issues are dealt with at the very highest level. He is also able to
manage complaints against the contractors, and to take those
decisions personally which will have expensive consequences for
the company such as ill-health retirements. He also ensures that
the OH contractors are fully signed-up with regards to company
health policy by coordinating conferences and providing
educational material. Another large rail organisation has recently
appointed a chief medical officer with a similar remit; an important
part of their work will be to ensure compliance by of the
outsourced occupational health providers.
Summary 5
The broad knowledge and experience of clinicians can respond to
the challenges facing the industry to address the adverse effects
of work processes and workplace hazards on employees. This
may also include the wider determinants of wellbeing as identified
by the Office of Rail Regulation (ORR) occupational health
programme. The broader utilisation of clinicians can be seen in
the in-house model, and a major challenge is to ensure that this
strategic wealth of knowledge is also made available where the
choice has been made to outsource occupational health.
Recommendation 5
Health commissioners in individual rail organisations should
ensure that their commissioning arrangements include the
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purchase of a quantum of senior strategic health input to provide
clinical leadership to enable the organisation to:
1 Deal with wider issues including the scope of occupational
health service, integration of health research such as
'Managing the risk associated with sudden incapacity in
safety critical occupations' (T663) and advice on specific
strategic issues
2 Ensure that wider health issues (including the adverse
effects of work hazards and processes on staff health and
the broader determinants of wellbeing) are addressed
seriously
3 Ensure that health policy is held to account at the very top
of the organisation
Who commissions
OH services?
It is natural that occupational health provision will focus on those
areas that are close to the hearts and mind of the sponsoring part
of the commissioning organisation. Occupational health services
are in general commissioned through human resources rather
than health and safety departments and so occupational health
professionals are largely accountable to HR departments.
Priorities through them focus on operational management
responsibilities for implementation of medical fitness decisions
made under the railway group standards. Thus, railway
occupational health is focussed on attendance management and
fitness of safety critical personnel to undertake their work.
Occupational health professionals described little direct contact
with safety personnel, and in many cases, were not aware of risk
assessments and direct involvement of occupational health
professionals with risk and safety professionals. Clinicians are
thus subservient to sponsors, so are not able to, for example,
initiate health surveillance, or to take a broader approach to
wellbeing as advised by ORR.
ORR has indicated that their inspections will 'evaluate compliance
with the law applicable to the particular health risk and take
enforcement action in line with our enforcement policy statement
to secure any necessary improvements'. It is obviously important
that contracting arrangements enable occupational health to play
their part in ensuring compliance - not to do so will put their own
health practitioners at some risk with clinical governance
processes as applied to health practitioners. OH practitioners
may find themselves in a difficult ethical situation when they have
identified a medical condition caused by work, but where a
12
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suitable risk assessment had not taken place and they know the
issue has not been strategically managed.
Case study: In the case of Thomas, Studholme and Rogan v
Arriva, Swansea County Court, 30th November 2009, His Honour
Judge Vosper QC found for the claimants (three train drivers) who
claimed that they suffered with Carpal Tunnel Syndrome, caused
by their work. He also commented "That the defendant failed in its
duty of care towards each of the claimants in failing to risk assess
the work system. Any such assessment should have identified the
shortcomings in the ergonomic conditions of the cab and
observed the individual habits of drivers which gave rise to risk of
injury. There was then a failure to take even the most modest of
measures to prevent or significantly reduce the risk of injury to the
drivers (that is, to fit and maintain adequate seating and arm
rests).
The study found little evidence of occupational health
participation in health surveillance, suggesting that either risk
assessments were not revealing any need for it, or else risk
assessments were not sufficient or extensive enough. This is
worrying for outsourced OH services as they may still share
liability for any subsequent claims.
Case study: One of the OH providers revealed that they had
been advised by their solicitors that they had to pay a share in the
settlement of a claim for Hand Arm Vibration Syndrome brought
against a large local authority where they had been the OH
provider, even though the employer had 44,000 employees and
its safety officers and managers had been responsible for
undertaking the risk assessments.
Summary 6
Occupational health in the rail industry tends to be commissioned
and accountable to operational managers and human resource
departments where it is measured and delivered in a transactional
fashion and focusses on sickness absence and safety critical
fitness. Hence the adverse effects of work hazards and work
processes on health and the broader determinants of wellbeing,
which may be held elsewhere in railway organisations (for
example with safety and risk managers) tends to be underplayed.
This is important in itself but change is also needed to avoid
enforcement action and to prevent the clinical governance
support for the health practitioners being compromised.
RSSB
13
Recommendation 6
Rail industry health commissioners need to ensure that
commissioning processes for occupational health are structured
so that services are commissioned and therefore accountable to
a broader range of interests within railway organisations,
including safety and risk departments. This will ensure that the
broader perspectives of occupational health as seen and set out
by the ORR are fully addressed.
RSSB and others might consider developing guidance on good
commissioning in the industry jointly with occupational health
bodies such as the Faculty of Occupational Medicine and/or the
Society of Occupational Medicine.
Communications and
health relationships
Communications difficulties between providers and contracting
organisations were observed on various levels. It was apparent
that there is a gap in understanding when considering railways
and medicine, both of which have strong cultures that are very
different from each other. Railways have a tradition based on
rules and certainties, whereas medicine concerns opinion and
probability, the two disciplines perhaps overlapping in the concept
of risk assessment.
 Rail managers often felt that they did not get the answers
that they wanted from occupational health management
reports and that such reports too often reflected the wishes
and views of the employee rather than their own.
 Clinicians commented that too often managers failed to ask
clear and direct questions and failed to give more than the
most minimum of information about their employees. They
also commented that line managers also sometimes failed
to understand exactly what an OH report actually says.
Occupational health reports advise managers and others of the
implication of adverse health on an individual's ability to
undertake their work or on the adverse effects of their work on
their health. Because of the potential for the findings to impact on
the individual's employment status or to initiate a legal claim, they
can be quite sensitive documents and hence the language used
is often quite subtle.
Case study: A senior clinician commented that if the only clear
information that they got was from the employee, it was hardly
surprising that OH reports could appear to mostly reflect this
input.
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RSSB
It seems there is a need for work in educating line and other
managers in the industry, to ensure that they get good value for
money out of their referrals. There is also scope for educating
trade union representatives in the role of occupational health and
how they can best support those members who need OH
opinions.
Case study: One large but dispersed non-rail organisation has
established a case referral unit, manned by human resource
officers working as case managers. As case managers they work
with and supervise line managers in completing OH referrals and
in interpreting their reports. They work closely with occupational
health and are able to interpret reports and explain their
significance to managers who may only very occasionally make
referrals.
Summary 7
Recommendation 7
Quality assurance
and health
relationships
There appears to be a poor understanding of the role of
occupational health amongst the frontline managers, and how to
get the best value for money from occupational health
professionals and providers. This will often require greater
commitment in completing referral forms and providing the
occupational health professional with sufficient information to be
able to make a balanced judgements and recommendation.
1 It is recommended that occupational health commissioners
take action to ensure that their line managers and other
occupational health referrers understand the purpose of
occupational health and how to make good occupational
health referrals; including what information the clinician
needs to give a cogent report and how to read and interpret
that report.
2 RSSB or others might wish to consider commissioning joint
work with bodies such as the Faculty or Society of
Occupational Medicine to develop guidance for managers
on completing referral forms for occupational health
opinion.
Many highly qualified clinicians employed within occupational
health providers are frustrated that they are unable to work in an
influencing way. Frequently, their input to the industry is restricted
to giving clinical opinions in what are sometimes very narrow
circumstances. OH practitioners may find it hard to gain
RSSB
15
experience and knowledge to provide improved value to the
industry.
Qualifications of
practitioners
Occupational health providers surveyed demonstrated a very
high level of qualifications in doctors and nurses. In no cases was
there any evidence of substitution of low qualifications (for
example, GPs with diploma instead of specialist accredited
consultant doctors) or substitution of cheaper professionals (for
example, replacement of nurses with technicians) which is
otherwise common in occupational health provision. The high
level apparent in railway contracts is unusual in occupational
health and demonstrates the seriousness with which existing
providers approach the industry. However in many cases, the
response of managers and commissioners suggested that they
were unaware of the senior skills and experience of the
practitioners contracted to them.
Some of the more experienced OH professionals expressed
frustration that commissioners and managers did not understand
the level of experience, training and expertise available to them.
Within this specialist clinical workforce a more strategic input into
employee health, beyond that currently provided by management
referrals and periodical reviews, could be made. However,
contract management processes such as KPIs just count
consultations and form a barrier in utilising clinicians in this way.
Strategic input might enable commissioners to obtain a more
targeted and cost effective service. In those settings both inside
the railway industry and outside of it, where occupational health
is at least partially an in-house function, it was evident that senior
clinicians were involved at a much higher level in the business.
This level of input meant that they were able to influence all of its
policies in such a way that health was integral to the
organisation's strategy.
Case study: an in-house provider of occupational health
remarked that because of their status they enjoyed a wide
influence within the company which was growing as they
continued to educate their colleagues in what could be achieved
from good occupational health practice. Their involvement
included participation in staff conferences, intranet, staff
magazines etc.
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RSSB
Summary 8
Many senior clinicians employed within occupational health
providers are frustrated that they are unable to work in an
influencing way. Their input into the industry is almost entirely
restricted to giving clinical opinions in what are sometimes very
narrow circumstances, against referrals which are lacking in
detail and focus
Recommendation 8
Commissioners and providers of occupational health need to find
ways of enabling their senior clinicians to work more strategically
with senior operational, human resource and safety managers.
These might include:
1 Regular quarterly health strategy meetings including lead
physicians, safety and human resource managers.
2 Inclusion of senior clinicians in media including staff
conferences intranet and company magazines.
3 Involvement and inclusion of senior clinicians in one-off
programs tackling issues where health may be a concern.
Experience,
expertise and health
relationships
Gaining access to the industry to understand its organisations is
much harder now than in the days of the integrated and
nationalised railway with its in-house occupational health service.
As occupational health provision to the industry has diversified,
practitioners find it much harder to gain experience and
knowledge to provide improved value to the industry.
Most of the large occupational health providers have made some
effort to ensure the exposure of their practitioners to the working
railway environment, either through informal educational
experience or workshop visits. However, this experience is not
available to those providers or practitioners who have yet to
secure a significant foothold in the industry. Information could be
made available to improve this situation, for instance, formal track
awareness courses exist and their availability could be better
promulgated to OH providers. Organisations such as ARIOPS or
RSSB could also make educational material available through
their website or clinical forum and conferences. This information
should be available to clinicians who aspire to work in the industry
as well as those who actually do so, without distinction.
Few providers appeared to have access to their commissioners'
intranets, and this prevents clinicians from gaining access to the
non-physical aspects of their commissioners businesses such as:
 Understanding the structure of the business through the
management tree
RSSB
17
 Becoming aware of important contracts inside the business
 Being able to view highly relevant documents such as safety
and human resource policies
Much of the day-to-day business of railway occupational health
consists of giving opinions regarding fitness to commence or
return to work in safety critical positions. Whilst observing the
workplace is ideal and important, it will never be feasible for this
to be part of every consultation. The industry is almost unique in
its history of documenting and recording every aspect of its
structure and equipment, and this information could be made
more readily available to occupational health practitioners so that
they understood the differences between the various workplaces.
Much of this information is already available in other places within
the industry, and with a degree of effort could be made available
through IT to occupational health practitioners. Good practice
identified in the study, included the making available of cab
passes to encourage railway practitioners to observe the
workplace of drivers.
Summary 9
Railway occupational health practitioners especially those
working in remote locations or as network physicians, have
difficulty in gaining workplace experience in the industry, or
obtaining information about it. The industry needs to consider how
it can improve this, so that a wider range of qualified and
experienced practitioners are available to the industry.
Recommendation 9
Railway organisations need to look carefully at how to enable
railway occupational health practitioners to better understand the
industry in which they work. This may include:
1 Cab rides, visits to signalling and control centres, and track
awareness courses are obvious opportunities.
2 Measures such as making intranet material available to
occupational health practitioners (including guidance
material regarding locomotives, multiple units, carriages
and stations), together with health, safety and human
resource policies.
RSSB should work with senior professionals in the industry and
ARIOPS to develop a suite of supporting information, to enable
new and aspirant entrants to the railway industry to get rapidly up
to speed in their knowledge of the industry.
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RSSB
Conclusion
It is clear from studying a number of documents published by
RSSB and ORR that there has been an interest in advancing OH
in the rail industry over the last ten years. Both RSSB and ORR
have published guidance on OH which is available on their
websites. Yet OH provision has failed to expand to fill some of the
gaps identified by ORR in its occupational health programs 2010
to 2014. There has been much consideration about setting up a
railway occupational health advisory board, but it is difficult to see
how such a body could on its own achieve the radical change in
occupational health relationships which are the focus of this
study. This discussion might lead to more successful and
enduring outcomes if it could become joined up and networked
across the industry to promote a higher common standard rather
than pockets of attainment.
Achieving
transformational
change in rail health
relationships
What is required is a greater commitment to providing a broader
focus of occupational health from railway organisations. CBH
appears to have achieved this in the construction industry and
because of the crossover between construction and rail
infrastructure, this initiative does seem to have some influence in
the railway industry. Significantly, one of the providers and one of
the commissioners outside of the infrastructure organisations
agreed that insufficient focus was being made on compliance with
the effect of work on health issues, and the research suggested
that this position was common and not unique.
Case study: a senior officer in a rail undertaking commented that
he regarded his organisation as 'barely compliant' with regard to
health issues. The provider organisation for the same undertaking
expressed equal concerns as to the sufficiency of risk
assessments of health issues, as it appears that little health
surveillance is taking place in that undertaking.
Ultimately the ORR as regulator can take enforcement action if it
feels that compliance is insufficient. Increasing spend on
occupational health has a short-term consequence for railway
organisations, but in reducing sickness absence, promoting
health and wellbeing and reducing harm to workers through
workplace hazards, an overall improvement in costs across the
industry can be expected, which will help to contribute to savings
in costs expected by the McNulty report. Another large
organisation outside the railway has also had to address its
internal concerns regarding the sufficiency of its approach to
workplace health, as the next case study illustrates.
RSSB
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Case study: about five years ago, amid growing concern
regarding the relationship between work and health the
Department of Health needed to consider whether its own
occupational health services for the NHS were fit for purpose. The
Department of Health provided the necessary clinical leadership
to encourage the improvement and development of workplace
health services for which they should be an exemplar. They
therefore commissioned a senior occupational physician from
outside the NHS, Dr Steve Boorman, to examine the service,
report and to make recommendations on it. He did this just at the
time that the SEQOHS accreditation scheme was being
introduced. This was a high-profile investigation and report, and
the work looked closely at NHS services and considered them
both strategically and pragmatically. As a result of this stimulus,
the NHS moved quickly to implement the SEQOHS scheme, and
to consider reconfiguration of services where appropriate so as to
achieve optimal outcome and efficiency.
Summary 10
The railway industry needs to consider its commitment to all of the
dimensions of occupational health as set out in the ORR Health
Programme 2010 to 2014. In particular it needs to consider how it
can address the challenge of expanding the focus of occupational
health to address the adverse effects of work on health and to
broaden the approach to wellbeing.
Ultimately ORR has the sanction of enforcement action, but this
is the least desirable approach. A high-profile industry driven
initiative similar to the Boorman report process used in the NHS,
or CBH may achieve a step-change in attitudes and
commissioning. This would be more effective if tied to
government initiatives such as the Public-Health Responsibility
Deal and backed up by senior national figures such as Dame
Carol Black and the Department for Transport. A national initiative
of this sort, will have a short term impact on all organisations but
avoid competitive disadvantage, which would itself be a risk if
decisive action from the industry regulator were to take place.
Recommendation 10
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RSSB
The rail industry should consider undertaking a national initiative
on the scale of CBH or the Boorman Report to encourage the
industry to commit itself to a greater focus on all of the issues of
occupational health as set out by ORR (not just safety critical
fitness and sickness absence). This would mitigate the risk to the
industry from a higher profile approach from the regulator through
enforcement action and reduce health risks thus far accepted by
industry.
RSSB
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22
RSSB
RSSB Workforce health and wellbeing project
Block 2 Angel Square
1 Torrens Street
London
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www.rssb.co.uk