RSSB Workforce health and wellbeing
project
Brief on the Health standards report
Introduction
This brief provides a quick glance at the main points made in the
'Health standards report'. The Health standards report has been
prepared to provoke discussion on how health standards use may
be improved within the rail industry. It looks at how the quality of
health management and practice could be improved by the
development and enhancement of standards, supportive
guidance and information. This brief initially sets out the current
UK position on rail fitness standards then considers the clinical
effectiveness of rail industry activity. Two external initiatives are
discussed, namely the ‘Australian national standard for health
assessment of rail safety workers’ and Constructing Better
Health, before setting out the report's conclusions.
The current UK
position on rail
fitness standards
Currently there are just two Railway Group Standards (RGS) that
cover the mainline railway in regards to health: GO/RT3451
covering train movement and GE/RT8070 covering testing
railway safety critical workers for drugs and alcohol. The purpose
of the current standards regime is to delegate to railway
organisations the maximum flexibility to operate standards as
they see fit.
In practice, most railway organisations have been disinterested in
taking full advantage of the flexibility which has been granted to
them by the industry. The extent to which individual rail
organisations have the capacity to take advantage of the practical
implications of such flexibility may be limited, in view of the lack of
in-house health/medical policy expertise in most railway
organisations. For example, following the development of
research project 'T663 Managing the risk associated with sudden
incapacity in safety critical occupations' individual rail
organisations failed to significantly improve the practical
interpretation of managing the risks associated with
incapacitation.
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.
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Brief on the Health standards report
In addition to RGS, railway occupational health practitioners may
need to be aware of six medical fitness standards utilised by
Network Rail (Competence specific medical fitness requirements
NR/L2/OHS/00124 (Issue 2)) and five medical fitness standards
enforced by TfL (S1601, S1602, S1603, S1604, S1605), together
with the guidance used by the Heritage Railway Association
(HRA). 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: undertaking an
individual medical risk assessment against a standard for safety
critical work, quite challenging for an occupational health
practitioner.
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 railway industry (including Network Rail (NR), TfL, light
rail and heritage railways) and make the recruitment and
management of occupational health providers much easier.
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) in respect the adverse effects of work on
health and wellbeing. This point is picked up by the Constructing
Better Health 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).
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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
Clinical practice for the last 25 years has been driven by an
initiative called clinical effectiveness. This is about evidencebased practice and delivering effective and cost effective 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
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Clinical Excellence (NICE). Organisations such as NICE develop
clinical guidance documents, using evidence-based methods,
incorporating clinical research. The aim of improving clinical
effectiveness includes not just what works, but at what price and
thus sometimes decisions can be quite controversial. 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. So
far, no organisation has as yet undertaken such work especially
focused on the needs of the UK railway industry.
Recommendation 4 Clinical excellence in
rail
The rail industry might want to consider whether they should be
more involved in the development of clinical effectiveness and
guidance material. This could include the development of clinical
guidance equal in scope and authority to that available overseas,
and which would support the current and future models of
standards.
Safe, Effective, Quality, Occupational Health Services (SEQOHS)
is a quality assurance initiative run by the Royal College of
Physicians on behalf of the Faculty of Occupational Medicine.
This scheme is a system of voluntary accreditation intended to
benchmark and kite mark occupational health services, covering
a range of domains including: business probity, information
governance, people, facilities and equipment, relationships with
purchasers, and relationships with workers. SEQOHS, which has
been developed specifically to cover occupational health practice,
has very rapidly been accepted by OH purchasers and providers
as a universal QA standard, possibly eclipsing the need for a
separate Link-up.
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.
Australian rail fitness
standards
The Australian 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. They focus upon
the railway organisation's systems for managing medical fitness,
and the associated medical evidence used by their physicians or
OH contractors.
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Brief on the Health standards report
Supporting these standards is a large body of fully referenced
supportive medical guidance, which refers to categories of railway
employee 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. The Australian standards also illustrate
the work environments to be found on the railway, including cab
design, controls and track placements.
There is also a detailed medical standards document covering the
New Zealand Railways (from a country with a similar healthcare
system to the UK). The Railways of Canada, through their
national government organisation, also supports a medical rules
document which is less prescriptive than the Australian and New
Zealand standards documents. Within the Canadian rail industry
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.
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 Association of Railway Industry Occupational
Health Practitioners (ARIOPS) would be a natural partner for this
work.
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. Such collaborative work might be facilitated by
RSSB's existing links with UIC and UIMC and would need to
consider the UK's need to comply with European legislation.
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Constructing Better
Health
Constructing Better Health (CBH) offers a complete occupational
health management toolkit designed for the construction industry.
It is well resourced and promoted by a high level body which
provides on-going team support in return for various membership
fees. The OH advice which CBH contains is cogent, easy to
understand and sets out clear principles and directions to follow.
It has a clearly written standards and a guide as to what OH
advice 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 a role that has occupational health responsibilities
attached to it.
The CBH scheme is especially good for infrastructure providers,
as they are often also construction organisations and it has had a
considerable impact on the new construction and renewal side of
the rail industry. However, it is not the same for TOCs/FOCs who
have a tradition dominated by the demands of meeting the
passenger timetable and where operating staff accept existing
environmental conditions, good or bad. While there is a long
history of an occupational health presence in these sectors, this
is almost entirely focused on ensuring the fitness of safety critical
personnel and managing attendance, two functions which are
sometimes in conflict with each other. In regards to the broad
determinants of wellbeing and the adverse effects of work on
health, where TOCs may be less proficient, the problem is as
much a choice in some cases to ignore the knowledge available
as it is a lack of knowledge.
Although CBH provides a potentially useful resource for train and
freight operating companies, its target audience is not currently
these rail organisations. However, rail organisations could use
their professional occupational health providers to access the
senior occupational health practitioners with the expertise
necessary to transform their management of health, and to
encompass those areas which are covered less well at present.
This would particularly benefit the management of the adverse
effects of work on health, and the broader determinants of
wellbeing.
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Brief on the Health standards report
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.
Conclusions
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.
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?
Recommendation 8 Increased health
provision through
standards
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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.