Examination of Witnesses (Questions 60-79)
MR PATRICK
MCDONALD,
MR STEVE
COLDRICK, MR
CHRIS WELLS,
DR PETER
WRIGHT AND
MS ANNE
KIRKHAM
22 NOVEMBER 2006
Q60 Chairman: Because it makes a
difference.
Mr McDonald: Volunteers
for the scheme will get extra training at Manchester University
who are running the overall core scheme for us.
Q61 Chairman: Right, and how can
you ensure that workers have access to occupational health services
and occupational health physicians across the board, or are you
now going to be relying on GPs who you are upskilling, which raises
the question, what about other members of the workforce and how
adequate is their access to advice?
Mr McDonald: I think
there is a general issue here where, certainly compared to other
countries in Europe, access to occupational health advice is not
as extensive. It is an issue that we need to consider, particularly
in the context of our EMAS statutory duties.
Q62 Lord Taverne: To follow up, on
the information about those suffering from allergic conditions
do you have any information about people whose genes may predispose
them towards particular allergies like occupational asthma?
Mr McDonald: Certainly
there is a genetic component to allergies, things like hayfever
and asthma do tend to run in families, but I do not think the
evidence base available to us is wide enough to be able to tell
specifically whether a particular genotype is responsible for
allergic reactions.
Q63 Baroness Platt of Writtle: What
action is the HSE taking to prevent individuals from developing
occupational allergic diseases? My mind flies to hairdressers
because there is no doubt about it there is a certain amount of
connection there, is there not?
Mr Coldrick: In fact,
yesterday on the specifics of hairdressers we launched the first
National Hairdressers' Day, which was aimed specifically at dermatitis
which, as we know, includes irritant contact dermatitis and allergic
dermatitis, and that is one of our major target audiences in respect
of skin disease which includes the allergic response. We have
put together, if you like, an alliance of the people who supply
the materials, the people who actually work with the hairdressers
themselves, the trainers, and also looking at the local authorities
who enforce. What we have learned in preparation for this campaign
is that it is not straightforward. If I give you a specific example:
some hairdressers feel that it is part of the job to have dermatitis
and in some cases asthma. In fact, we had an e-mail from somebody
who had been doing it for 34 years saying, "Stop whingeing
and just get on with it and accept it," so there is an attitude
problem. The second problem that we have is that when it comes
to taking what are very sensible and simple precautions for protecting
against allergic skin disease, dermatitis, hairdressers and salon
owners shy away from that because they believe that the customers
will not like hairdressers to wear, non-latex disposable gloves.
So this campaign has been about dispelling some of the myths,
and to get an attitude change, not only amongst the salon owners,
not only amongst the hairdressers, but also amongst the clients,
and that is the whole thrust of the campaign of which the Hairdressers'
Day is a part. The campaign goes up to 20 December, but we are
continuing because when you are talking about behaviour and attitudinal
change we measure that in years rather than weeks.
Q64 Baroness Platt of Writtle: What
proportion of employers comply with legislation to provide a safe
workplace for allergy sufferers and what procedures are in place
to deal with employers who do not comply?
Mr Coldrick: It is
very difficult to answer the first question because within that
there is a presumption that we know everything about everybody
and that also there is a turnover of business from year to year,
so there are businesses which are in business now which we and
others do not know about, so it is very difficult to answer that
question. What we do have, though, is a targeted approach. In
the context of hairdressers, if I may stay with that, we have
got a suite of approaches. First of all, we are trying to raise
awareness and get people to understood causation and be committed,
because it is just commonsense. Part of that is for the local
authority environmental health officers (who are the regulators
in hairdressing of health and safety matters) who as part of the
disease reduction programme are visiting about 20,000 hairdressers
over the coming year. Initially they will be taking the bag of
materials which will demonstrate the use of gloves and moisturising
cream, which is an essential component, but later in the programme
we will be turning to enforcement. We want to give everybody the
chance first to see the light before those who will not then need
to feel the heat.
Q65 Lord Broers: According to your
evidence The Health and Occupational Reporting Network have reported
a decrease in new cases of occupational asthma and work-related
contact dermatitis in recent years. How robust are these data?
Mr McDonald: As you
will gather from the answer to the first question I was asked,
there is some variability in this data and trying to find the
numbers from the generality of common, multi-causal illnesses
is a real challenge for us. What we do is collect information
from a fairly broad range of sources and carry out a semi-quantitative
integration, which is a rather fancy way of saying it is a well-informed
judgment, and we use the important lead source for each of those
data and then use other sources to guide our interpretation. Because
it rests so much on judgment, we have been very keen to make sure
that this work is peer reviewed, so we had a workshop at the beginning
of the revitalising health and safety statistics which started
in 2000 to test the robustness of our approach. We subsequently
then discussed the approach with the Government's Statistical
Service Methodology Committee and then there has been further
external peer review as we have produced the figures. So our judgments
on progress are published, along with our reasons for those numbers,
as is the external peer review of what we are doing. What is important
to us are trends rather than absolute numbers in what we do as
an Executive. It is consistency over time which is the key criterion
for us, for our robustness, and, as you say, THOR is the lead
source for occupational asthma and contact dermatitis. We have
asked Manchester University to do some further research and statistical
modelling on these figures. The data are not perfect but they
are certainly robust enough to support the general statements
that we make about health and safety. Again, we are trying to
look at this on a wider basis so we have a programme of evaluation
that actually looks at the impact of our various interventions
and assessing changes in good practice and changes in behaviour
in our target groups. That way we hope to have a much more beneficial
impact on the prevention of occupational asthma and contact dermatitis.
Q66 Lord Broers: The difficulty with
trends is that it does not help us with international comparisons
necessarily, does it, as we discussed with the previous witnesses,
and you say the differences in data collection procedures make
international comparisons of work-related allergy prevalence problematic,
so what do you plan to do about it?
Mr McDonald: We are
part of two EU working groups—the European Statistics of
Accidents at Work and the European Occupational Disease Statistics—trying
to standardise the position for work-related illness and injury.
It is hugely challenging because we have all got very different
systems of collecting statistics and we have very, very different
cultural norms in terms of what is reported in workplace health.
Whilst I welcome having established working groups, I do not think
they are going to come to any useful conclusions any time quickly.
Q67 Lord Colwyn: So are you assuming
that everybody who has contact dermatitis or asthma always goes
to see a doctor?
Mr McDonald: It is
a population-based survey. There is a real problem with these
multi-causal illnesses and when somebody presents to the GP, the
GP is not necessarily going to think of occupational health as
the first cause, so that is why we rely on the self-reported survey
which would have a tendency to over-report but at least gives
us some confidence that we are picking up a reasonable indicator
of the prevalence of illness.
Q68 Lord Broers: You have set yourself
a target of reducing occupational asthma and allergic contact
dermatitis by 10 per cent by 2008 from a 2004 baseline. What practical
measures are you implementing to meet that target?
Mr Coldrick:
That falls to the Disease Reduction Programme. What we have within
that programme relevant to this inquiry are two projects, the
respiratory disease project and the skin disease project, and
we are targeting particular populations with the highest incidence.
Just as I referred earlier to hairdressers, which is one of our
target audiences, we are seeking to lead by working in partnership
with all key stakeholders and influencers, including role models,
ie in the case of hairdressing, to actually raise the level of
awareness, get the understanding, gain the commitment, and achieve
the behaviour change, and that is what the project is actually
focused on. So it is a multi-stranded approach. It will be going
through supply chain pressure, where possible, through trades
unions' support, where that is relevant, education, to catch the
people as they enter the particular target sector, to make them
aware as to what the right thing is to do, and then also to raise
awareness by those already in that particular target sector, to
get them to understand what they need to do and why they need
to do it, and in most cases why it is relatively simple; it needs
an attitudinal change. Finally, of course there is always the
regulatory enforcement role. It is what you might describe as
a best mix approach to those particular sectors.
Q69 Lord Colwyn: Do you have figures
for the current level of industrial injuries disablement benefit
being paid to employees from allergic disease and what sort of
shape is the graph; is it rising rapidly? Could I also ask you
at what stage is the employee labelled as having an allergic disease?
Dr Wright: The first
part of that answer is the industrial injuries scheme essentially
starts payments if disability or disablement is present on the
91st day, so the first 90 days are not covered at all. Then after
that the level of payment will depend on the degree of disablement,
and in most cases of people with allergic disease that is likely
to be relatively low. You have heard earlier about the possibility
of more severe disability through complicating asthma, for example,
and there the permanent disablement figure will be rather higher.
In general terms, given the fluctuating nature of the disease,
the levels of payment are likely to be quite low. The standard
for an 18-year-old and over at the moment who is 100 per cent
disabled—that is really severely disabled—will be
£127 a week, so we are likely to be talking about something
substantially less than that, probably if there is a persisting
disablement something of the order of 20 or 30 per cent, where
you are talking of something around £25 or £30 a week.
In a number of instances there will be, in essence, no permanent
disablement but the potential to become disabled, and that may
well fall below the 14 per cent threshold which applies and means
that no payment is made. In terms of numbers, we are trying to
get you some numbers. That may sound a bit lame but this is an
old and rather small part of the benefits system and it is not
on our computer systems, so we are trying to see if we can get
you some figures and if we can we will send them to you, but the
answer in general terms is that they are likely to be relatively
low. As I have already explained, there are considerable restrictions
by which people with allergic diseases are covered by the scheme
and, of course, they have to meet the particular criteria of prescribed
diseases that come within payment at all, so the numbers will
be low. In general, numbers of people entering the scheme are
staying roughly stable overall. We still have a situation that
approaching 40 per cent are due to accidents. We are talking of
no more than 10,000 new entrants a year and 40 per cent odd are
due to accidents. 60 per cent are due to diseases. Vibration white
finger and pneumoconiosis are the largest numbers; allergic diseases
are very small numbers. There is no suggestion that there has
been any great change in numbers, but that may not reflect the
incidence of the disease because it is such a selective group
that comes in. If we can get figures, and we have asked for them
over the years, we will provide them to you.
Q70 Lord Broers: Could you give any
details of what retraining schemes or other schemes are available
to ease reduced earnings for these poor people who are unable
to carry on their work?
Dr Wright: Reduced
Earnings Allowance was in fact closed from 30 September 1990 so
recipients either received it before that date or, if they are
applying now, it is because they had an accident or a disease
which started before that date. It is simply a payment towards
loss of pay. I stress the word "towards" because it
still exists for the reasons I have mentioned, and it was always
capped, and in fact the current maximum rate for Reduced Earnings
Allowance is £50.84 a week, so it is only a partial contribution.
That is not to say that people who have a disability are not helped
within the system. One of the things that happened when it was
closed was that a parallel provision was made for anybody with
a disability, so when Reduced Earnings Allowance was first introduced
as a Special Hardship Allowance it only applied within the industrial
injuries scheme. Disability Working Allowance, which is now part
of the Employment Tax Credit, is available to anybody who has
a disability which puts them at a disadvantage in the labour market,
so those who cannot receive Reduced Earnings Allowance would have
access to the tax credit system to help them. In terms of saying
programmes to help people, retraining and so on, that will be
attached to Jobcentre Plus through the normal programmes for people
who are unemployed or people who have a health condition and are
on Incapacity Benefit, and you will be aware that there are proposals
to change Incapacity Benefit and the extent and the amount of
help that is offered to people on that benefit.
Q71 Lord Taverne: I want to ask about
anaphylactic emergencies in schools. The Anaphylaxis Campaign
is setting up a national training programme to educate school
nurses on allergies because it feels the Government is not doing
enough. What training is there for school nurses, and teachers
for that matter, for dealing with such an emergency in a school?
Mr Wells: If I can
take this question in a couple of parts, firstly just to answer
it but then also to give you a bit of wider context as to how
we would expect health services and educational and social care
services to be thinking generally about work strategies that may
help the Committee understand what we are about. First, as I am
sure the Committee are aware, all school nurses are trained nurses
and many are qualified children's nurses, and this means that
they will all have had some training and experience in the management
of anaphylaxis. It is true to say that many nurses working in
schools have access to training courses run by the Anaphylaxis
Campaign, which is a well-regarded course, and to a certain extent
although the way the question was framed is perfectly reasonable,
I do not know that we should have a fear about them having to
run a campaign or a course because many such organisations do
just that. Lots of people will access courses run by the British
Dyslexic Association or the National Autistic Society, so it is
quite commonplace in fact for organisations with a particular
specialism to design and run courses for the benefit of a whole
range of professionals in different services, and that provides
them with an income stream, so there is a value in that. In addition,
it will be the case that primary care trusts and others will run
courses which are relevant for nurses to access as well. It is
in fact the case that any nurse who administers an immunisation
in a school setting will receive anaphylaxis update training on
an annual basis. That is a requirement of their own continuing
professional development. School nurses who are involved in the
delivery of such immunisations and other access treatments who
have a particular knowledge will themselves be engaged in delivering
training to school staff. I said I would give you a little bit
of background context, if I might. There is a major government
programme which is partly in answer to another question that you
asked the earlier bodies about inter-departmental collaboration.
The Every Child Matters Change for Children programme engages
in a whole wide range of departments, and obviously as far as
this particular inquiry is concerned the two departments, mine
and the Department of Health, are critical. One of the key parts
of the programme is to ensure that in every local area there is
a Children's Trust and that that Children's Trust owns a children
and young people's plan. That plan is basically a commissioning
plan, it identifies the key presenting needs in any area, it sets
priorities for delivering better services to meet those needs
and critically, in relation to my Lord's question, there will
be a local workforce strategy agreed by the various partners that
are targeting a particular training initiative that is necessary,
and indeed they may commission it themselves. The other thing
I ought to just mention—and I am not sure if the Committee
has got a copy—is we have recently produced some guidance
called Managing Medicines in Schools. It is joint guidance
from the Department for Health and the Department for Education
and Skills. It sets out a framework in effect for ensuring that
there is effective practice in schools to support children with
a number of allergic conditions, including those who are prone
to anaphylaxis, and there is guidance and advice in there as well
which is of an information nature.
Q72 Lord Taverne: Thank you and what
is the Department's policy on the use of auto injectors by teachers
and students?
Mr Wells: We would
not want those to be used, as it were, just on the teacher's judgment
but where there is a child who is prescribed an Epi-pen or some
other therapy, and there is an agreement between the parents and
the school for a teacher to administer it in the case of anaphylactic
shock, and the appropriate training can be delivered to that teacher,
then we would support it. In other words, if we just step back
again, the guidance I mentioned Managing Medicines has
as part of its ambition that where we have children with particular
medical needs that there is an individual health care plan, and
if that plan identifies that a child carries (or one is held at
the school for) an Epipen or adrenaline shot treatment, then there
is no reason why the teacher should not deliver it. We would not
advocate teachers just holding a stock of those "just in
case" because they would not have the judgment, we believe,
to decide whether or not the child in front of them is suffering
from that shock or some other need.
Q73 Chairman: In your answer you
outlined the training for school nurses and, to a certain extent,
for teachers, but I wonder what ongoing audit is there to make
sure that they do have appropriate level skills because we all
know that you can take people into a training programme but that
they have learned to apply those skills is not necessarily the
case.
Mr Wells: No, that
is fair comment. The answer to the question though has to be made
through local judgment because, to a certain extent, it is rather
impossible for a central department to make a judgment as to what
is the best way of developing the school's workforce in 33,000
different settings. What we are expecting every school to have
are a number of policies, including policies which are related
to the support for children with medical conditions, medical health
needs, and then to secure appropriate training for their staff
on a needs basis. There is a significant amount of money at head
teachers' disposal for just that purpose, to ensure that they
are developing their school workforce to meet a wider range of
demands in addition to teaching and learning, which is obviously
their core business. Is does rather depend on the locality.
Q74 Chairman: Is there a requirement
for those skills to be assessed regularly because you could take
a school and have people trained, the boxes are ticked, you then
have a child who has an anaphylactic reaction, but although the
boxes have been ticked the skills are not there at the time?
Mr Wells: I would
certainly agree that the key thing for us is to ensure that there
is a depth of understanding of the need and the risk that the
school is trying to address. We are very, very keen to ensure
that people do not just have tokenistic strategies, tokenistic
policies, against which they tick boxes, indeed to that extent
we are rather against model policies because they tend to weaken
people's engagement in understanding what particular risk they
have in their setting and indeed to ensure there is a wider ownership.
In fact schools have got a number of statutory duties which we
believe are ensuring that school governors and head teachers are
taking their responsibilities—basically to address the question
as you put it my Lord Chairman—to ensure they have got staff
who do have the necessary training. It is a head teacher's responsibility
to ask themselves whether the cadre of teachers and support staff
they have is capable of delivering across a broad range of issues,
not just allergy, if I can say so.
Q75 Lord May of Oxford: I have a
question which, in a sense, is a continuation of this but in the
specific context. If another of DfES's good schemes goes well
there is one category of an anaphylactic shock which is going
to be on the marked increase, I would guess, namely the programme
on transforming school food, replacing unhealthy snacks with healthy
foods. We all know from the tabloids it is having what we might
call "teething problems" with concerned parents turning
up to feed their kids junk food through the fence. But supposing
it does go well, then the snacks kids eat are more likely to be
the sort of thing I have just been eating at the morning break,
seeds and nuts, which is one of the major causes of worry in this
area. Specifically, against the background of the discussion we
have just had in general, to what extent do you see a particular
need to really ramp things up a little bit and address very seriously
some of the questions which have been asked, not just about ticking
boxes of procedure, but making sure people really are on key for
this?
Mr Wells: There are
a few things, if I might. First of all, we would expect the parent
of the child who has the particular allergy to ensure the school
understands that the child has that particular allergy. If I can
refer back to one of the answers I gave earlier, that is then
the starting point for agreeing an individual healthcare plan
for that child.
Q76 Lord May of Oxford: None of these
kids may ever have eaten a nut or a seed.
Mr Wells: If I can
move on, they are going to have eaten one once. If I can at least
work on the assumption that the vast majority of parents are likely
to become aware of a child's allergy before a school is presented
with the reaction to not knowing. The first thing is to make sure
the knowledge is shared and the knowledge is understood by a wide
group of adults within the school setting so that if they see
the incident, if they see the reaction, they can react. The second
thing, of course, is to make sure that teachers generally are
aware of the likelihood that certain nuts and other foodstuffs
can indeed give rise to a shock. I think it is important to recognise,
although I respect the question, that nuts are not the only likely
cause of anaphylaxis, eggs are, cows' milk can be, fish can be,
indeed I heard a reference earlier on to latex, latex can be;
you cannot ban everything that could give rise to a shock. What
is important is that, first of all, there is a clear understanding
that a child is at risk, that the child itself understands it
is at risk, and that adults are looking for incidences that could
give rise to it. In that sense, we are very clear as a general
nature of training and updating teacher's knowledge that must
be part of the school's expectation of itself and, indeed, that
we are helping schools understand the need for good hygiene generally
because in extreme cases, as of course you will know, very allergic
children could react to traces of allergens which have just been
left on furniture, et cetera. It is a rich question which requires
a rich answer, I think, and we are trying to make sure there is
a good level of understanding across the piece.
Q77 Lord Colwyn: It is a question
I probably should know the answer to. If a child is given a shot
with an epi-pen and, in fact, they are just suffering from a temporary
obstruction, apart from an increase in heart rate, does it cause
any harm?
Mr Wells: I am not
competent to answer the question. My understanding is in general
no, and in general, in any case, back to the answer I gave earlier,
even where we do have a child where there is an agreement that
the use of an epi-pen is advisable, there is also a requirement
that a medical service is called instantly. I think where we are
being more careful here is that we do not want to encourage the
general use of that treatment amongst untrained folk, and that
is after all what teachers are. My understanding is that what
I am saying would also apply to, for example, doctor's receptionists.
They would not just use it without some prior knowledge of its
likely success. In relation to your particular question, I am
afraid I do not know the answer to the extent if it could cause
harm.
Chairman: If I might intervene, I think
it is dose-related so that if you give an overdose, and that would
happen if you used the wrong pen, the wrong dose for a particular
child, then you certainly could run into problems, possibly cardiac
problems too. They are not things just to be taken lightly.
Q78 Lord Colwyn: Would a school have
supplies of different pens with different doses?
Mr Wells: No, it
is child-specific.
Q79 Viscount Simon: Again, just going
a little bit further, what procedures are currently in place to
help students go about their everyday life with allergic diseases
in schools and universities?
Mr Wells: If I can
take the university bit first, if you do not mind, because it
is a relatively short answer. They are adults and there maybe
a number of different services which would help them manage their
own conditions. To a certain extent, we would expect the arrangements
that would be made within the university to mirror those you would
expect to find in the workplace. There is clearly an expectation
amongst adults that they would carry their own treatments and
they would be aware of their own condition. Nonetheless, universities
are large institutions, they will have access to health services,
they will want to make sure they are promoting the well-being
of their students, and they may very well have their own arrangements.
It is not something that we regulate, however, or establish from
the centre. As far as schools are concerned, there is a relevance
to the answer I just gave. As a child becomes older it becomes
an expectation that they will become more able to hold and indeed
administer their own treatment and every support should be given
to that. We would be looking to school nurses and other health
professionals to work with the child, the parent and the school
to ensure that as a child is able to take greater control of their
own health, they are enabled to do so. That might, for example,
mean helping a child know where it can store certain medicines.
Some medicines are controlled, as, of course, you will know. My
general point comes back to an answer I think I have given twice
already, so apologies, that we would expect every school, whether
the child is five, 15, 19 or indeed younger than five, every school
to have an individual care plan for that child, and there is an
agreement updated periodically to make sure that everybody knows
how to deal with that case on its own terms. It is quite critical,
of course, that the family is involved in these circumstances
themselves. It is quite critical to recognise that some parents
will encourage a greater level of school involvement in their
child's health than others. Indeed, some might be actively resistant
to the school being involved in the delivery of the basic treatments
et cetera. We have to try and respect all those different shades
of opinion against a clear understanding that there is a health
and safety requirement on all schools, just as there is in any
other public building, and there is a duty in the Education Act
to promote well-being.
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