Health standards report
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Table of Contents
Health standards report
Introduction and purpose of report .................................................................................1
Findings and recommendations ......................................................................................1
The current UK position on rail fitness standards ...........................................................1
Railway group standards for medical fitness ............................................................1
Flexibility to operate standards ..................................................................................1
Changes in rail standards ..........................................................................................2
Non-RSSB UK rail medical fitness standards ............................................................2
Scope of UK medical fitness standards .....................................................................3
Clinical effectiveness and the rail industry ......................................................................3
What is clinical effectiveness? ...................................................................................3
Who is responsible for clinical effectiveness? ...........................................................4
What about clinical effectiveness in occupational health? .........................................4
How has clinical effectiveness influenced medical practice? .....................................4
Clinical effectiveness and quality assurance in OH practice ......................................4
Australian rail fitness standards ......................................................................................5
Fitness categories ......................................................................................................5
Structure of Australian rail fitness standards .............................................................6
Medical guidance in the Australian rail fitness standards ..........................................6
New Zealand and Canada ........................................................................................6
Healthcare systems comparator ................................................................................7
Guidance to OH practitioners regarding the railway work environments ...................7
Constructing Better Health .............................................................................................8
What is Constructing Better Health? ..........................................................................8
Ownership of CBH .....................................................................................................8
Content of CBH ..........................................................................................................8
Continuity of CBH ......................................................................................................8
Guidance for managers in CBH .................................................................................8
Standards and CBH ...................................................................................................8
Coverage of occupational health in CBH ...................................................................9
Matrix of jobs in CBH .................................................................................................9
Lessons from CBH for railway occupational health practice ......................................9
Summary: the potential for CBH approach in railway health practice ........................9
Conclusions .....................................................................................................................10
Workforce health and wellbeing project
Health standards report
Introduction and
purpose of report
This report has been prepared to provide information to improve
health policies and standards use within the rail industry. It will
examine how rail organisations can improve health management,
through the development and enhancement of health policies and
standards. It will also look at how the quality of health practice can
be improved by the development of supportive guidance and
information.
Findings and
recommendations
The report reviews the current UK position on rail fitness
standards, then focusses on two external initiatives, Constructing
Better Health (CBH) and the ‘Australian national standard for
health assessment of rail safety workers’, as well as considering
the impact of the clinical effectiveness initiative.
The current UK position on rail fitness standards
Railway group standards
for medical fitness
Medical fitness to operate trains has been a concern of railway
organisations since the early days of the railways. The railway
group standards (RGS) for medical fitness have been managed
by RSSB since its inception in 2003. Since then, apart from the
usual minor revisions, there have been major alterations to
structure and content of the standards, such that currently there
are just two standards: GO/RT3451 covering Train Movement
and GE/RT8070 covering Testing Railway Safety Critical Workers
for Drugs and Alcohol.
Flexibility to operate
standards
In particular, a number of vocational standards have been
combined into the current Train movement standard
GO/RT 3451. This offers flexibility to railway organisations to
operate standards as they see fit, although in practice, most
railway organisations have been disinterested in taking full
advantage of the flexibility. For example, following the
development of the RSSB research project Managing the risk
associated with sudden incapacity in safety critical occupations
(T663), individual rail organisations failed to significantly improve
the practical interpretation of managing the risks associated with
incapacitation.
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Health standards report
The extent to which individual rail organisations have the capacity
to take advantage of the practical implications of such a flexibility
may be limited in view of the lack of in-house senior occupational
health (OH) expertise in most railway organisations. In fact one of
the interviewees for the fieldwork undertaken for the Health
relationships report would prefer to return to a more prescriptive
and wide-ranging portfolio of medical fitness standards.
2
Changes in rail standards
Frequent changes to standards creates a special difficulty for
occupational health practitioners; they may have a portfolio which
covers many industries and within which railway organisations
may comprise just a small part.
Recommendation 1
Flexibility
Industry should consider whether they value, or are able to use,
the maximum flexibility in setting standards, or would industry be
more effective if it returned to a more prescriptive and detailed
approach.
Non-RSSB UK rail medical
fitness standards
Additionally, railway occupational health practitioners may need
to be aware of the six medical fitness standards utilised by
Network Rail (Competence Specific Medical Fitness
Requirements NR/L2/OHS/00124 (Issue 2)) and the five medical
fitness standards enforced by TfL (S1601, S1602, S1603, S1604,
S1605), together with the Guidance used by the Heritage Railway
Association. Separate medical fitness standards may also be
maintained by operators of other guided transport systems such
as light rail and Tramway operations. Such complexity makes a
relatively simple medical assessment task ie that of undertaking
an individual medical risk assessment against a standard for
safety critical work, quite challenging for an occupational health
practitioner, however well-qualified or experienced who may have
difficulty keeping up with changes interpreting different hearing
standards for example, especially if they are only spending a
small proportion of their time in the industry. The question has to
be asked as to whether it is possible to align and converge all of
these standards and to satisfy those railway organisations who
feel that the standards as currently maintained by RSSB are not
sufficiently wide-ranging or comprehensive. For this reason, the
study considers in some depth the Australian rail fitness
standards, which cover all guided transport in Australia including
heritage and light railways with just four categories of worker and
a very detailed and prescriptive set of medical guidance for
occupational health practitioners.
RSSB
Recommendation 2
Scope of railway
Industry should consider the introduction of a more uniform and/
or/less complex range of medical standards which would cover
the whole industry (including TfL light rail and heritage railways)
and make the recruitment and management of occupational
health providers much easier.
Scope of UK medical
fitness standards
The medical fitness standards managed by RSSB and others are
restricted to the implications for safety critical work. They do not
relate to the important agendas recently identified by the Office of
Rail Regulation (ORR) concerning the adverse effects of work on
health and wellbeing. This point is picked up by the CBH
standards, which also include standards referable to wellbeing,
sickness absence and the adverse effects of work on health.
Some of these standards are covered by statutory obligations (for
example lead, asbestos, vibration, COSHH) but some, which may
not be spelled-out in quite the same way, are dependent on
making a suitable and sufficient risk assessment (for example
ergonomics, respiratory and skin surveillance). It seems that
many UK rail organisations have quite extensive occupational
health support, but this is largely restricted to the management of
sickness absence, together with consideration of medical fitness
for undertaking safety critical tasks both pre-placement and whilst
in service. The report will explore the potential for following a
similar approach to CBH in extending the existing mandatory
standards to include voluntary standards which would apply to
well-being and the adverse effects of work on health.
Recommendation 3
Scope of health
The rail industry should consider the usefulness of introducing
voluntary standards for those areas of health management
identified by the ORR as in need of development but are not
covered by industry standards/guidance.
Clinical effectiveness and the rail industry
What is clinical
effectiveness?
Clinical practice for the last 25 years has been driven by an
initiative called clinical effectiveness. This is about evidencebased practice which requires the undertaking of focused medical
research, and putting this research into practice by identifying the
most appropriate processes for delivering effective and costeffective clinical outcomes and pathways for care. Clinical
guidance is provided to clinicians by a number of sponsoring
organisations often paid for by the government, such as the
National Institute for Health and Clinical Excellence (NICE).
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Health standards report
Who is responsible for
clinical effectiveness?
Organisations such as NICE develop clinical guidance
documents, using evidence-based methods, incorporating clinical
research, with the aim of improving clinical effectiveness, which
includes not just what works, but at what price and thus
sometimes decisions can be quite controversial.
What about clinical
effectiveness in
occupational health?
In recent years, a number of organisations such as the Health and
Work Development Unit at the Royal College of physicians, the
British Occupational Health Research Foundation (BOHRF,
actually now closed) and NHS Plus have developed clinical
guidance specifically for workplace health, again often with
government or charity funding. So far, no organisation has
undertaken such work especially focused on the needs of the
railway industry, although much of the material which has
appeared as clinical guidance in RSSB documents, supporting
existing medical standards, could be described in this category.
How has clinical
effectiveness influenced
medical practice?
It is no longer considered acceptable medical practice to make
decisions outside of clinical guidance. Rail physicians will
therefore often consult and even cite other documents from
comparator environments, such as the DVLA guidance known as
’at a glance’, and clinical guidance prepared for other safety
critical settings, for example the Armed Forces, aviation and
maritime settings.
Recommendation 4
The rail industry might want to consider whether they should be
Clinical excellence in rail more involved in the development of specific clinical effectiveness
and guidance material related to the management of health in rail
organisations and infrastructure providers. This decision should
also bear in mind the considerable cost involved, the current low
quantum of academic occupational health practice in the UK, and
the absence of a particular institution focused on the needs of rail
industry.
Clinical effectiveness and
quality assurance in OH
practice
4
RSSB
The clinical effectiveness initiative (which was led by the
Department of Health) has also encompassed the evaluation of
clinical practice itself, leading to the development of quality
standards. One initiative is the Safe, Effective, Quality,
Occupational Health Services (SEQOHS), developed by the
Royal College of Physicians on behalf of the Faculty of
Occupational Medicine, specifically to cover occupational health
practice. This has rapidly been accepted by purchasers and
providers as a universal standard (possibly eclipsing the need for
a separate Link-up). This scheme is a system of voluntary
accreditation intended to benchmark and kitemark occupational
health services, covering a range of domains including: Business
probity, Information governance, People, Facilities and
equipment, Relationships with purchasers, Relationships with
workers. This scheme has been taken up widely across the
occupational health industry and is likely to become virtually
universal in a short period of time.
Recommendation 5
Clinical excellence in OH
provision
The rail industry should consider integrating Link-up into the
SEQOHS scheme, possibly by having an additional specialised
rail domain, in a similar way to the specialised NHS domain used
by NHS occupational health units.
The rail industry might want to consider whether they should be
more involved in the development of clinical effectiveness and
guidance material, including the possibility of developing clinical
guidance equal in scope range and authority to that available
overseas.
Australian rail fitness standards
The Australian medical rail fitness standards, (latest edition
October 2012) have been in existence for almost 10 years, and
are orientated around fitness to undertake safety critical work.
There is no consideration of the adverse effects of work on health,
and the reader is referred elsewhere for advice on this aspect of
workplace health. Likewise there is no mention of the
management of sickness absence and little consideration of the
broader aspects of wellbeing other than the direct impact of
lifestyle issues such as alcohol.
Fitness categories
The Australian rail fitness standards are centred around four
categories. These are:
1 Category one workers require high levels of attentiveness to
the task and for whom sudden incapacity or collapse, such
as from a heart attack or blackout may result in serious
incidents affecting the public or the rail network, for
example, single operator train driver.
2 Category two workers also require high levels of
attentiveness but for whom there are failsafe mechanisms
or the nature of their duties ensures that sudden incapacity
or collapse will not affect the safety of the rail network for
example, signallers.
3 Category three workers are normally around the track
personnel (ATTP) who operate in an environment where
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Health standards report
they may be at risk from moving rolling stock. As with
category one and two they are required to have health
assessments to identify relevant health risks.
4 Category four workers are ATTP workers who do not
actually work around the track and hence are not at risk
from moving rolling stock and therefore are not required to
have health assessment under this standard. The areas in
which they work are areas which have been risk assessed
to identify hazards and where controls are in place to ensure
that any person working in or transiting the area is of
minimal risk from moving rolling stock.
6
Structure of Australian rail
fitness standards
The Australian rail fitness standards document was designed for
use by occupational physicians employed by the railway
organisation or its occupational health contractors. It covers the
systems for managing medical fitness by a railway organisation,
and includes a detailed gazetteer of medical conditions, similar to
that set out by the DVLA guidance. The standards include clear
directions as to how the medical conditions will impact on each of
four categories of rail worker as set out above.
Medical guidance in the
Australian rail fitness
standards
Accompanying these standards, and carefully developed so as to
support them, there is a large body of fully referenced supportive
medical guidance which refers to each of these categories in
respect of each medical condition. This approach is quite
prescriptive, although the individual practitioner will undertake an
individual risk assessment where appropriate. This body of
Australian rail medical guidance is of potential value to UK
occupational health practitioners, as it provides a source of
information to supplement existing online guidance from the
DVLA. Since it is fully referenced to medical literature it will be of
advantage to practitioners who need to justify the individual
medical risk assessment.
New Zealand and Canada
There is also a detailed medical standards document covering the
New Zealand Railways, (from a country with a very similar
healthcare system to the UK). The Railways of Canada, through
their national government organisation, also supports a large
medical rules document which is less prescriptive than the
Australian and New Zealand standards documents. In Canada
there are no medical standards as such; the rules document
essentially serves as guidelines for the Chief Medical Officers of
Canadian railroads when carrying out fitness assessments either
directly or via reports obtained from treating physicians.
RSSB
Healthcare systems
comparator
Australia and New Zealand’s healthcare systems are similar to
the UK’s, and are based on the principle of universally accessible
primary care, which gatekeeps the more expensive secondary
care. Canada has a healthcare system which is different from UK
practice, being closer to the US system and less dependent on
gatekeepered primary care. Again none of these medical fitness
documents cover areas beyond fitness to undertake safety critical
work, and they do not venture into the areas of wellbeing/sickness
absence or the adverse effects of work on health.
Guidance to OH
The Australian rail fitness standards illustrate the work
practitioners regarding the environments to be found on the railway, for example, they
railway work environments include cab design, controls and track placements. This
information covers the whole range of guidance systems,
including tramways.
Recommendation 6
Development of clinical
guidance
The rail industry should consider the scope for developing
material specifically targeted at occupational health
professionals, illustrating railway environments, cab design, and
job design and tasks, to help provide guidance to railway medical
professionals who do not have direct access to these
environments.
The rail industry should consider whether the four categories in
the Australian rail fitness standards (which represents a
considerable simplification of the standards applicable in the UK)
could be adapted in the UK to enable the provision of a more
uniform service. This would require discussions taking place with
the owners of the other medical fitness standards, particularly
Network Rail (NR), Transport for London (TfL), The Heritage
Railway Association (HRA) and the operators of the various light
railways and tramways, to explore the scope for any common
interest.
The rail industry should consider whether the UK could
collaborate with Australia, New Zealand or Canada, or all three,
in developing joint clinical guidance and/or medical fitness
standards in future which could also cover TfL, NR, HRA and
tramways/light rail.
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Health standards report
Constructing Better Health
8
What is Constructing
Better Health?
Constructing Better Health (CBH) is a complete occupational
health management toolkit designed for an industry with a low
starting baseline on workers’ health issues. It is well resourced
and promoted by a high level body which provides on-going team
support in return for various membership fees.
Ownership of CBH
CBH has been accepted by the construction industry, and where
used, given rise to a sense of pride. In most cases it seems to
have been taken up at the highest level and is commonly held
within the portfolio of a Board member. A senior interviewee
quoted that health was his number one priority.
Content of CBH
The OH advice which CBH contains is cogent, easy to understand
and sets out clear principles and directions to follow. It is not a
book of reference full of occupational health advice, but a clearly
written guide as to what to obtain, why and how to obtain such
advice. and is written by some of the occupational health
professionals’ senior leaders (Ray Quinlan and Geoff Davies). It
is written from the perspective of the specialty of occupational
health rather than from the perspective of an outsider (unlike
Management of Health Needs or the web pages about
occupational health on the ORR website).
Continuity of CBH
Because CBH is a membership organisation, it employs staff who
have a responsibility for continually updating the information and
the other products which it sells, by contrast for example, with
governmental websites, which may not enjoy this level of support.
Guidance for managers in
CBH
CBH sets the tasks of managing health out clearly in a step-bystep fashion for those unfamiliar this field. It tells managers
exactly what they must do, explains why they must do it, how to
go about doing it or how to engage somebody who can do it for
them. There is lots of back-up support provided in return for the
membership fees.
Standards and CBH
CBH sets out a number of standards, some of which are ‘must
do’s’. The ‘must do’s’ are set out in legislation and relate to
significant hazards such as lead or asbestos and others which are
not backed by statute but which are also important. CBH does not
make clear in each case as to the exact mandatory nature of each
standard, which acts to encourage a previously non-compliant
industry long associated with harming its workforce, to overcomply.
RSSB
Coverage of occupational
health in CBH
CBH provides a continuous spectrum covering the effects of work
on health, wellbeing (including sickness absence management)
and fitness for work, including safety critical work. Membership of
the scheme provides access to the scheme’s accredited
Occupational Health service providers (OHSPs). For accredited
OHSPs, who are members, the scheme provides access to the
market place of corporate and affiliate members.
Matrix of jobs in CBH
The matrix is especially effective at mapping out the various jobs
undertaken in the construction industry, and their needs for
occupational health and linking this to the standards.
Lessons from CBH for
railway occupational
health practice
It is still early days as regards the initiative, and its final evaluation
including costs and impact has yet to be determined.
The CBH scheme is especially good for infrastructure providers
as they are often also construction people and has already had a
considerable impact on the new construction and renewal side of
the rail industry. The matrix, as already developed, already
overlaps with the needs of the railway infrastructure industry, and
could fairly easily be extended to cover rail organisations.
For TOCs/FOCs, there is a long history of an occupational health
presence oriented towards ensuring the fitness of safety critical
personnel and managing attendance, two functions which are
sometimes in conflict with each other. As regards the broad
determinants of wellbeing and the adverse effects of work on
health, where some TOCs may be less compliant, the problem
could be one of lack of knowledge or some cases, no positive
choice is made.
Additionally, the language of CBH is orientated around the needs
of the construction trade which it is culturally quite different from
for example, train operators. There is little crossover with the
range of jobs, and before CBH could be applied to train and freight
operators, the range of range of jobs focussed in the jobs matrix
would need to be considerably extended, and the culture and
language re-orientated to match that of rail organisations.
Summary: the potential for
CBH approach in railway
health practice
CBH is a useful resource which has already led to a considerable
improvement in the approach of the construction industry to
occupational health.
This has had a knock-on effect already on the infrastructure
providers, guided as they are by Network Rail itself. However,
although CBH provides a potentially useful resource for train and
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Health standards report
freight operating companies, culturally it is not written for the rail
organisation audience who already have access through their
professional occupational health providers to very senior
occupational health practitioners, who could provide the expertise
necessary to transform their management of health, and to
encompass those areas which are covered less well at present,
particularly the management of the adverse effects of work on
health, and the broader determinants of well-being.
Recommendation 7
Managing the effects of
work on health
The industry should consider asking RSSB to develop a ‘rail
organisations’ version of CBH, perhaps by adapting and
extending the original material, and contextualising and badging
it to meet the rail organisation’s culture. This would lead to an
improved focus on the adverse effects of work on health (for
which appropriate standards are included in CBH), and which
through risk assessment might increase the quantum of health
surveillance being bought through occupational health. As CBH is
a membership organisation, this would add to the costs of the
industry but it would help rail organisations to make better use of
the expertise of their existing OH providers.
Industry should consider commissioning extension of the jobs
matrix in CBH, to apply to the needs of rail organisations, which
would provide a structure within which to risk assess the various
forms of employment undertaken within rail organisations. This
would provide a focus for health surveillance activity, and would
complement the risk assessments which are required for
workplaces and health and safety regulation.
Conclusions
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RSSB
CBH and the Australian rail fitness standards together offer an
approach to creating a management structure for delivering
comprehensive occupational health in the rail industry. The
Australian standards are a source of relevant clinical guidance to
enable an occupational health practitioner to reach an evidencebased conclusion when faced with many different clinical
dilemmas. However, these standards and guidance are entirely
focussed on the issue of workers' fitness for safety-critical work
and does not attempt to cover the important area of the adverse
effects of work on health or the wider dimensions of wellbeing.
CBH offers an approach moulded to the needs of the construction
trade, ensuring that by means of voluntary and mandatory
standards, the whole of the field of occupational health is fully
covered.
Recommendation 8
Increased health
provision through
standards
It is worth considering the current railway health standards regime
in light of the different perspectives available from other
industries. Can the regime be altered to create more effective
health provision?
Industry should consider combining the approach of CBH and the
Australian rail fitness standards to create an integrated product
focussed on the needs of the industry.
This may include:
 Voluntary and mandatory standards for rail workers
occupational health provision
 A simplified system of classifying rail workers' safety
standard encompassing the needs of the whole industry
 Comprehensive clinical guidance for occupational health
professionals and detailed information for them on job roles
and locations in the industry.
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RSSB
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