Health and Safety standard

Karen Markes, Occupational Health Manager

The University is committed to providing a safe and healthy workplace.  Some employees may be required to work with substances or processes that if incorrectly controlled could impact on their health and wellbeing.

The aim of this Standard is to set out the arrangements and duties for the provision of suitable health surveillance programmes with the aim of protecting employees from work related ill-health during the period of their employment.  The need for health surveillance will be identified when a risk assessment indicates that checks are needed to ensure that controls that have been put in place remain effective.

The aim of health surveillance is to monitor and protect the health of individual employees by detecting, as early as possible, any adverse changes that may be caused by certain work practices such as exposure to substances hazardous to health, noise and vibrating equipment, as well as assessing the fitness of individuals to carry out their role.

This Standard should be read in conjunction with the following University Standards:

• The Management of Asbestos
• Confined Spaces
• Control of Substances Hazardous to Health (CoSHH)
• The use of Nanomaterials
• Driving for Work
• Diving for Scientific and Archaeological Research and Teaching
• Fieldwork
• Genetically Modified Organisms (Contained use of) 
• Noise at Work
• Ionising Radiation Management
• Laser Safety Management
• Vibration at Work
• Electromagnetic Fields

Health and Safety at Work etc. Act 1974

Management of Health & Safety at Work Regulations 1992

The Control of Asbestos at Work Regulations 2002

The Confined Spaces Regulations 1997

Control of Substances Hazardous to Health Regulations 2002

EH40 Workplace Exposure Limits Supplement

Driving at Work: Managing work related road safety 2014 (INDG 382)

The Diving at Work Regulations 1997

Modified Organisms (Contained Use) Regulations 2014

The Control of Noise at Work Regulations 2005 (SI 1643)

Ionising Radiation Regulations 2017

Control of Artificial Optical Radiation at Work Regulations 2010

The Control of Vibration at Work Regulations 2005

The Control of Electromagnetic Field Regulations 2016

Control of Lead at Work Regulations 2002

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013

Depending on the nature, frequency and duration of exposure undergraduate students may not require health surveillance as defined in this Standard.  Any work undertaken by undergraduate students should be risk assessed to ascertain need for health surveillance.

Members of the public.

Employees

Individuals employed directly by the University; including honorary contracts, part-time and full time contractors and temporary workers, visiting academics and Postdoctoral Researchers/Postgraduate Researchers (PGR)/Postgraduate Taught (PGT).

Staff working in areas where risks to health are being managed may be required to take part in a health surveillance programme.  In the event that health surveillance is required it will be part of the contractual obligation of staff.  Please contact HR Services with any queries.

Health Surveillance

Health Surveillance is a process involving a range of strategies and methods used to systematically detect and assess the early signs of adverse effects on the health of workers exposed to certain health hazards, and to determine the fitness of the employee to carry out designated tasks.

Certain procedures are required to be put in place to achieve this.  These procedures include:

• simple methods, such as looking for skin damage on hands from wet work or using certain chemicals
• technical checks on employees, such as lung function tests and hearing tests
• other medical examinations such as blood or urine tests

Health surveillance is not a substitute for controlling health risks – managers must ensure that all reasonable steps are taken to reduce the risks of exposure to the lowest level reasonably practicable.  Health surveillance must be undertaken where there is a residual risk of exposure when all control measures have been put in place.

Health surveillance provides managers with information which helps them to take steps to protect employees from ill-health caused by being potentially exposed to health related risks at work.  It enables managers to manage these risks effectively by checking:

• how control measures (for example local exhaust ventilation) are working; and
• where managers need to take further steps

Risk

A risk is the likelihood that a hazard will actually cause an adverse effect, together with a measure of the effect.

Hazard

A hazard is something (e.g. an object, a property of a substance, a phenomenon or an activity) that can cause adverse effects.

RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013)

Contact the Health and Safety and Occupational Health Teams to discuss and arrange health surveillance training.

Identification of persons/tasks requiring health surveillance

Managers have responsibility for ensuring local arrangements are in place for appropriate health surveillance to be identified, arranged, carried out and acted on.  Line managers will:

• Include requirement for health surveillance in local induction checklists to ensure referral into the health surveillance programme at start of employment
• Complete a Health Surveillance Needs Assessment form to ensure that a suitable and sufficient assessment has been undertaken that identifies the hazards.  If hazards are identified the manager must complete the assessment with employees to ensure that all work tasks are fully understood
• Identify and inform staff groups for whom health surveillance is required, working with Health and Safety and Occupational Health Services, and HR Services if required
• Explain the process to staff to ensure they understand why they are being provided with health surveillance and their responsibility to engage in the process
• Allow workers requiring health surveillance the time to attend the programme that is established for them
• Review need for health surveillance (Health Surveillance Needs Assessment) on at least an annual basis and/or following changes in work activities or physical building infrastructure that may change any previous controls

‌Health Surveillance Needs Assessment Form

Referral for health surveillance to the Occupational Health Service

The line manager who has responsibility for undertaking the risk assessment for the work is responsible for identifying the need for health surveillance or health monitoring.  When a need for health surveillance is identified, following completion of a Health Surveillance Needs Assessment, managers are required to complete, in discussion with the identified person, a Health Surveillance/Health Monitoring Registration Form 

Once the form is received by OHS the individual will be contacted to arrange an appointment.  At the appointment the individual will be informed of the reason for health surveillance/health monitoring and what form it will take.

Manager

Occupational Health Service

Deciding that health surveillance is required

Following a referral, the OH Adviser will (in conjunction with the appointed Occupational Physician where required) assess the appropriateness of health surveillance on the likelihood that an identifiable disease or adverse health effect will result from or may be related to exposure.  The following factors are considered:

(a) Type and extent of exposure
(b) Assessment of current scientific knowledge such as;

(i) Available epidemiology (study of human illness in populations)
(ii) Information on human exposure
(iii) Human and animal toxicological data and
(iv) Extrapolation from information about similar substances or situations

The health surveillance appointment

Health surveillance is mandatory for those staff identified as requiring it.  All staff who are requested to attend an OHS appointment for health surveillance must attend.  The OHS and line managers will do everything they can to ensure staff attend these appointments but continual failure to attend or engage in the process may ultimately result in HR disciplinary proceedings.

Health surveillance tests such as respiratory health surveillance, audiometry, hand arm vibration assessment, and dermatological assessment following referral to OHS will be completed by the Occupational Health Service.

All staff

Managers

HR Services

Occupational Health Service

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‌PD42 Drivers eye test form

The results of the health surveillance

The individual and their line manager will be advised, in writing, of the outcome of the Health Surveillance Programme by OHS within 10 days of the appointment so far as possible.  The outcome report will include:

• The hazard for which health surveillance was undertaken
• The outcome in terms of fitness to undertake a particular work activity and, if necessary, whether restrictions from work are advised
• Timescale for review health surveillance

The results will indicate:

• Any exposure to hazardous substance, which indicates a risk to the individual’s health
• Non-performance or under-performance of risk control measures

Action required as a result of health surveillance

The OHS may advise the individual’s line manager on changes to any future exposure, controls or working arrangements which may be necessary to protect the individual from further exposure to the hazards identified.

Occupational Health Service

Manager

HR Advisors

Health & Safety

Recall process and review

The need for continuing health surveillance is reviewed as appropriate and will depend on the working conditions and the actual exposures of the individual to the hazard.  This review assessment is carried out by an OH Adviser or Occupational Physician on an individual needs basis and will be communicated to the employee and the line manager following the initial appointment.  Where repeat appointments are required an individual will be entered into the Health Surveillance Programme and called for appointment according to a defined schedule set by the OHS.

Manager/All staff

University trends and reporting

Record keeping

Individual, up-to-date health records of exposures to hazardous substances under CoSHH and exposure to asbestos must be kept by the University for at least 40 years after the work with the substance has ceased for each employee placed under health surveillance.  For Ionising Radiation health records should be kept for at least 30 years.  Health records should include details about the employee and the health surveillance procedures relating to them.  Health records should not contain any confidential medical information.  Information on health surveillance record keeping can be found on the HSE website.

Occupational Health Service

Reporting unplanned exposure incidents

Any event resulting in the accidental release of, or exposure to, anything that could be hazardous to health should be reported on the University incident reporting form so that this may be flagged with the Occupational Health Service and, if deemed appropriate, by the Health and Safety Team.

Where required, Occupational Health will advise on the health surveillance requirements following accidental and unplanned exposure incidents occurring at work.  This will include appropriate clinical investigations and medical follow-up if deemed necessary.

Occupational Health Service

Incident Reporting

Information, instruction and training

Information regarding health surveillance and detailed information on some aspects of health surveillance where self-assessment is required can be found on the Occupational Health Service website.

Managers should actively seek to provide information to all staff where hazards are present including the risk assessment, safe systems of work/safe operating procedures and arrangements for health surveillance.

Occupational Health Service

Biennially the Standard Lead for the Health Surveillance will carry out an audit to ensure that all elements of the Standard are being implemented effectively across all aspects of the Standard.  Specifically the following will be measured:

Carry out a biennial review (on a sample of departments) to establish the number of managers who have completed the Health Surveillance Needs Assessment.  This sample will be selected according to the tasks and processes carried out which are likely to give rise to health surveillance needs.  The sample will represent all Faculty and Professional Service areas.

Of this sample, an assessment will be made to include as a minimum:

• routine health surveillance has been completed or is in progress
• action has been taken following the results of health surveillance

Where employees have been indicated for health surveillance:

• OH record keeping is appropriate
• Managers’ record keeping is appropriate
• Information, instruction and training has been provided on induction and with regular refresher training