Examination of Witnesses (Questions 280-299)
Professor Anthony Newman Taylor, Mr Rob Miguel, Professor
Raymond Agius and Dr David Orton
10 JANUARY 2007
Q280 Earl of Selborne: Professor
Newman Taylor in his written evidence refers to the need to provide
a means to support retraining for individuals with occupational
asthma for the facilitation of new jobs and presumably there is
a need for other occupational allergic diseases and you refer
to the review of the Industrial Injuries Scheme. Could we hear
from you—and I am sure Mr Miguel will want to come in on
this also—on what you would like to see as the outcome of
this review of the Industrial Injuries Scheme and what new training
schemes or other measures might be appropriate?
Professor Newman Taylor:
If I can focus in terms of the review of the Industrial Injuries
Scheme on how it impacts on this, one of the problems with the
Industrial Injuries Scheme at the present time is that the way
in which benefits are provided for prescribed diseases and industrial
accidents is uniform. It is essentially a benefit which is provided
for so-called loss of faculty, that is to say impairment, and
the level of disability which is caused by that. If one thinks
of someone who has occupational asthma, and dermatitis may be
similar to this, if you can identify the disease sufficiently
early there is the potential for it to resolve completely. Take
someone who has occupational asthma due to, let us say, to being
a baker working with flour. The major problem they have is that
they are unable to return to work in an environment where they
come into contact with flour or the enzymes that are added to
flour in the baking process. What we need to put into place is
a system which provides support to enable them to retrain and
go into alternative employment. The problem for many cases of
occupational asthma, and there have been several studies that
have looked at this, is that somewhere between a third and a half
of cases of occupational asthma remain unemployed three to five
years later. They have had to leave their work because of the
risk of progression of the disease if they remain there and of
it becoming chronic and are unable to find alternative employment.
What I was suggesting in that letter is that the Industrial Injuries
Scheme could have a benefit which could be applied to that. There
was a benefit called Reduced Earnings Allowance. Reduced Earnings
Allowance was introduced originally in the late 1940s with the
Industrial Injuries Scheme which enabled people who had pneumoconiosis
to move into other jobs where they were less exposed to coal dust
and therefore less at risk of progressing to Progressive Massive
Fibrosis, so it had a very important preventive role in terms
of coalworkers' pneumoconiosis. It was an earnings replacement
which enabled that to occur. That was withdrawn by the Government
of the day in 1990 and so that is no longer available. What I
would hope in the reform of the Industrial Injuries scheme is
that there will be a benefit, which could be time limited, which
would be focused on providing occupational rehabilitation and
retraining for people who have those conditions, of which asthma
is a notable example, where continuing exposure leads to progression
of the disease and the appropriate route to take is avoidance
of the exposure. At the moment people may not bring their disease
to attention because they are concerned they will lose their job
and will not get another one, so we are in the worst of both worlds.
Dr Orton: I would
agree wholeheartedly with Professor Newman Taylor's aspirations,
but with regard to the skin there are a couple of complicating
factors. The evidence at the moment suggests that if people with
occupational skin disease change their employment it may not always
result in a significant improvement in the prognosis for those
individuals. There is also the condition of PPOD, or persistent
post-occupational dermatitis, which is when somebody develops
dermatitis in an occupational setting and you then remove them
from that occupational setting and the exposure, yet their dermatitis
persists. There is some evidence from Australian large-scale studies
that up to 10 per cent of the workforce within their study group
developed this particular condition, so that also has to be taken
into account when one is considering retraining or taking people
out of various employments when they develop dermatitis.
Q281 Lord Taverne: What training
do general practitioners receive about the treatment of occupational
allergic diseases? It has several times been stressed, and now
again by Professor Newman Taylor, that what is so important is
early diagnosis. Do GPs receive sufficient training in the diagnosis?
Professor Newman Taylor:
I would think it unlikely. Occupational health and occupational
disease are not usually a part of the undergraduate training programme.
It is not seen to be usually as important a part of a general
practitioner's training as the other conditions which they may
see and so therefore their knowledge of these conditions is probably
not great. Added to that, the number of cases that they will see
individually is not going to be huge and so therefore their experience
and the need to understand this is not as great as it might be.
My answer to your question is that I think it probably is not
enormous. We have run a clinic for patients with occupational
lung disease, the majority of whom have occupational asthma, and
we see about 250 cases a year, and of the order of 5 to 10 per
cent of those patients are referred to us by general practitioners.
It is a relatively small proportion of the cases that come to
us. The majority come to us from occupational physicians or from
other specialist physicians.
Professor Agius:
By training I am a specialist in occupational medicine and I have
never practised in general practice. However, I am involved in
undergraduate medical education in a number of British medical
schools, including my present one. Sadly, I think it is fair to
say that the level of training that the average British graduate
gets in the recognition of occupational allergic disease is exceedingly
limited to the extent that when we set up, about 18 months ago,
a scheme for recording reports of occupational allergic disease
emanating from general practice, because they are, if I could
use the analogy, at the base of the pyramid as compared to specialists,
we felt we could not rely on the average general practitioner.
We had to select from the few thousand GPs who have what is called
a "Diploma in Occupational Medicine", and even then,
in my judgment, they rarely have had the sort of training which
the average graduate ought to be getting but is not.
Q282 Lord Taverne: Given the importance
of this, both in terms of the impact on individuals and the quality
of their life and of the economy in general, are representations
not being made to try to secure much greater priority for training
in this for medical students?
Professor Agius:
Yes, representations are being made. For example, the Centre,
and the Faculty of Occupational Medicine to which I belong has
yet again, and has done so in the past, embarked on initiatives
to bring this to the attention of medical educators. I think what
tends to happen is that there are lots of other specialities and
interests, with good cause, vying for their own special features
to appear in the curriculum but, given the fact that most people
will present in the first instance to their GP and that such a
huge burden on health could be prevented at that stage by early
recognition and early steps, yes, I do believe more should be
done to train GPs.
Dr Orton: I agree
with my colleagues in the points they have made today. Even in
dermatology the undergraduate curriculum usually consists of only
two weeks' attachment, whereas 20 per cent of all GP consultations
involve some form of dermatological problem. We have to tackle
it from another angle because what we need to do is improve the
pathway of the patient. Obviously, the GP has to be aware that
occupational allergic disease exists but it is getting that patient
through to specialists as soon as possible that we have to concentrate
on.
Q283 Lord Rea: How often is the subject
of occupational allergic disease—asthma or dermatitis—included
in postgraduate programmes organised by postgraduate deans for
general practitioners, for trainee general practitioners, for
registrars and principals in practice? There are these courses
all the time going on. How often do they include an element of
occupational health, including allergy?
Professor Newman Taylor:
My answer is that I suspect it is in a minority. I do not have
definite data but I am very familiar where my colleagues and I
are asked to talk, and we give many talks to postgraduate meetings.
It is a minority of those for general practitioners; the majority
is for other specialists.
Chairman: I think it is probably a question
we need to ask the GPs in relation to that.
Q284 Baroness Platt of Writtle: To
which specialists do GPs refer patients suffering from occupational
and allergic diseases and how often do these referrals happen?
Professor Newman Taylor:
I would have thought that they would refer them particularly to
respiratory chest physicians for occupational asthma and dermatologists
for skin conditions. Those are probably the two most commonly
referred because those are the circumstances in which the cause
and effect relationship is clearest. Clearly, somebody who has
occupational deafness may be being sent to an ENT surgeon, but
there is nothing to distinguish that deafness symptomatically
from deafness that occurs in the population as a whole. I am unable
to speak for other clinics but from my perspective, the majority
of the occupational lung disease cases referred to me, come from
occupational physicians, nearly two-thirds; a third from other
specialists; and 5 to 10 per cent is from GPs.
Q285 Baroness Platt of Writtle: Then
to take the two major causes, considering a number of people suffer
from occupational dermatitis, are there currently enough specialists
in that area and will there be a potential shortage of specialists
when the present cohort of occupational asthma specialists retire?
Professor Newman Taylor:
The situation with occupational asthma is that I think there is
a need for a relatively small number of sub-specialists who have
this as a particular interest. The reason there needs to be a
small number—it is not something which all chest physicians
can provide—is because there are particular factors which,
in terms of understanding the nature of work, the relationship
of work to the asthma, the investigation of the cases, which can
include inhalation testing, and then the management of the case
subsequently which need interaction between employers and others
involved in the future management of these cases. It seems to
me that it is important there should be a number of specialists
in this field, not least because it is very important to identify
a case because, as I said in terms of asthma, you have the chance,
if not of cure, at least of improvement. I would agree with my
colleague that not all cases of asthma resolve, but the majority
will improve when they avoid exposure. Equally devastating is
if you say to somebody, "Your asthma is caused by your work",
and it is not, "You need to change your job", and they
do so and they do not need to have done it. That, I have to say,
is something which I see not infrequently because of a lack of
knowledge of what is needed to make a confident diagnosis so you
can give confident advice. There are six or seven specialists
within the UK who have this as a particular interest and it is
the case that many of us are now reaching retirement age. I think
that there is a real need to ensure there will be successors,
otherwise experts in the field will go. That is something which
I would say at the moment is not secure.
Dr Orton: I would
agree with all of those points. With respect to dermatitis, it
is very important to have sub-specialists with a particular interest
in occupational disease because that is going to provide at the
end of the day the best management for the individuals who come
to see them. Equally, within dermatology, many of my colleagues
who have an interest specifically within occupational dermatology
are also coming to retirement age and there does not seem to be
the number of individuals coming through who have a particular
sub-specialist interest in this area, so there is going to be
a problem in the future almost certainly.
Q286 Chairman: Is there also a problem
in terms of the number of consultant posts that are not being
renewed now?
Dr Orton: Without
getting too much into a political statement here, dermatology
is a speciality under threat also, being moved from hospitals
into a primary care setting and, indeed, much of dermatology now
being undertaken by primary care physicians—and this of
course here, relates to the previous question—they will
not have received any specific training in occupational dermatology
so we are entering a downward spiral here which I can only see
as a future problem.
Q287 Baroness Platt of Writtle: Whose
responsibility would it be to put this right, because for both
allergies you are saying that there are retirements and this is
going to be a problem? Who should be taking it up?
Professor Newman Taylor:
I would suggest that the Department of Health needs to take responsibility
with regard to this and I say that because for any individual
hospital moving into the era of foundation trust status, where
clearly financial viability is an extremely important issue, we
are talking about two specialities where the revenue which will
be received in terms of patient care is certainly not as great
as, let us say, somebody who is going to need to be in an intensive
care unit. If there is going to be an area where people will wonder
is this in fact an area where we should continue to focus on,
it must be one of the areas that a chief executive must wonder
for the reasons that I have given. Occupational dermatitis and
asthma will be services that will be at risk. In those circumstances,
unless there is either Department of Health or, a specialist commissioning
process where there are funds made available for it, which is
the way it probably can best be done, I can see this as something
which no individual hospitals might see as their responsibility
to continue.
Q288 Viscount Simon: Professor Newman
Taylor, you have mentioned the specialists to whom patients can
be referred. Is there any particular reason why you have left
out allergists?
Professor Newman Taylor:
In the main, no, I have not really, but the reason that I am focused
on respiratory physicians and dermatologists is that the majority
of these sorts of patients are referred to them. If you have allergists
who have a particular interest and have received training in occupational
disease then, of course, within their area of interest there is
no reason why that should not be appropriate. The majority of
allergists have focused on hay fever, asthma and dermatitis, the
broad spectrum of it rather than focusing on the occupational
component.
Q289 Lord Broers: What course of
action would typically be recommended for a patient suffering
from occupational asthma or allergic skin conditions, and at what
stage is a patient advised to give up work?
Dr Orton: First of
all, within normal practice we would make a risk assessment for
this individual and we would perform the necessary investigations
to arrive at a diagnosis, whether it is allergic, irritant or
both, and whether there are constitutional susceptibilities. As
I mentioned briefly, giving up work is not always the answer because,
certainly with regard to dermatitis, it does not always significantly
lead to an improved prognosis. There are cut and dried cases where
it is purely an allergic contact dermatitis and the patient is
meeting that particular allergen only in the workplace. There
are some allergens which are found not only in the workplace but
also in the domestic environment and part of the management for
that particular patient is teaching the patient about these exposures.
However, in the clear-cut cases it is sometimes necessary for
these individuals to leave work, particularly if they are volatile
allergens and there is not going to be any way that they can avoid
exposure in their current place of work. Obviously it is very
difficult to give a generic answer to this and each case must
be taken on its own merit and has distinctive features.
Professor Newman Taylor:
Talking about asthma, in part it relates to the nature of the
agent and in part the severity of the asthma which is occurring.
One has to look at it against the background that the evidence
that there is would suggest that the longer you continue to be
exposed to the cause of your asthma, the greater the chances are
the asthma will become irreversible, so there is a need in the
individual case to avoid exposure both to prevent acute reactions
and also the risk of progression. Agents such as isocyanates,
which are volatile chemicals, are extremely difficult to avoid
sufficiently if you become sensitised to them and to prevent the
progression of asthma. In general, for people exposed to chemicals
such as isocyanates, one would recommend that they should avoid
exposure in some way, and to the extent that it is possible one
looks to try and see if relocation is possible within the factory
or workforce in which the person is involved. There are other
allergens, particularly with particulate agents, such as flour
or laboratory animals, where it may be possible to enable people
to continue at work wearing sufficient respiratory protection.
That certainly I would advise in circumstances where it provides
the individual with the time to look for and obtain other employment.
If you have got someone, for instance, who is a PhD student and
is two years into it one would work quite hard to enable them
to complete their PhD which also gives them a year in which they
can look for alternative employment, let us say working with tissue
rather than live animals. It is not hard and fast, but clearly
the aim is to avoid exposure.
Mr Miguel: My Lord
Chairman, on the employment issue, it is very difficult because
a lot of these people go to their GPs and their GPs may advise
them to give up work, but that does not necessarily mean the employee
is going to go back into work and give their job up, they may
work on. We have done some work with certain employers regarding
security of employment policy, whereby they re-deploy those people
in the same plants in different rolls,—Rolls-Royce is a
good example. Which leads to a further question, if they do have
to give up work what sort of training is available to them? There
was a mention of the benefits system, to clarify a point, reduced
earnings benefit at the moment is being replaced by working tax
credit. However, the benefits system itself does not help people
to get back into work because if you have a look at the benefits
system, one example, you need to be off work for about 30 weeks
before you can claim for your mortgage. If you go back into the
workplace, you lose that benefit and start from square one; I
think they allow four weeks grace. Who in their right mind is
going to go back into the workplace, or be encouraged to go back
into the workplace when they are going to lose this type of benefit
and they have to start from square one again? For example, they
would have to wait for 30 weeks to have a mortgage payment. The
benefits system is not helping at all. The diagnosis and the fear
of medical confidentiality breach's are not helping. We would
like to see a proper government-led training initiative for people
with allergies which involves job centres, where job centres are
aware of industries where these allergies occur, and to re-train
those people at the same skill level as they had before, getting
the same pay because what we are trying to do now, is to say to
them "You are no good for this job now, or, you can do this
job where it is half the pay and we will try and top that up using
tax benefits". In fact, it does not work so I think we need
to look at the benefit system quite carefully, look at the way
the diagnosis is happening, and how the information is getting
back to the employer, because the employer, or the job centre
are not getting adequate information or using it correctly.
Q290 Lord Broers: How much do you
get involved with small companies? What if it is a small paint
shop where they are flagrantly ignoring safe practice? Do you
get much involved with that, if these might be organisations of
only half a dozen people?
Mr Miguel: Unfortunately,
trade unions are usually involved with big organisations, but
I do get involved with small organisations of about 50 employees
where they have this sort of problem. I do not want to name the
companies here, but we do get involved, I do go on to site and
give them advice because they have limited knowledge on re-deployment,
on allergies, on information about what is an allergy, and what
is a sensitiser but very rarely, because trade unions are more
involved in major companies than smaller ones, but that is changing.
Q291 Chairman: Given the shortage
of specialists that there is and the importance from the Union's
point of view of accurate diagnosis, which you highlighted earlier
on, has the Union thought about developing its own service and
employing an allergy specialist itself, or part-employing an allergy
specialist itself?
Mr Miguel: No, that
is not something we consider. We do work with employers and their
occupational health departments, but we do not think that it is
the trade union's role to supply specialists, it is the employer's
role to do that.[1]
Q292Lord May of Oxford: This is a question
that probably reflects my ignorance. We have heard that one of
the major sources of allergies was among hairdressers and I was
under the misapprehension that a great proportion of hairdresser
outfits were small businesses. Am I wrong, because if I am right
then that means that is a really very significant problem, of
this issue not being addressed because you are typically dealing
with larger outfits?
Mr Miguel: I will
answer that very quickly. They are small businesses yes and they
have got very little occupational health advice, although the
HSE is trying to bring the schemes forward, so, therefore, the
campaigns which we talked about earlier are very relevant to reaching
those small businesses and some of the media tactics that I mentioned,
but, you are quite right, they are small businesses in need of
help.
Q293 Lord May of Oxford: They sum
up to a large number.
Mr Miguel: Yes.
Dr Orton: I would
like to comment on that. Amongst hairdressers, in occupational
skin disease, allergy is a part but irritancy is probably a greater
part. In my own practice and when I am talking to other dermatologists,
the days of going into a large industry and looking for large
outbreaks of sensitisers causing problems are very much lower
than they used to be. It is usually the smaller industry and smaller
workplaces where the majority of patients now seem to be coming
from.
Q294 Lord Rea: The Health and Safety
Executive regularly convenes a group of occupational respiratory
disease specialists with the aim of developing a document setting
out standards of care for the diagnosis and management of occupational
asthma to circulate throughout the medical community. What recommendations
do you think should be included in this report? Am I right in
thinking that this group is the same or related to SWORD? It seems
to be very much covering the same area.
Professor Newman Taylor:
I think it is a different group from SWORD. SWORD is the reporting
scheme, which Professor Agius is now responsible for; GORDS is
an informal group of respiratory physicians who have an interest
in occupational disease which has been convened by the Health
and Safety Executive and meets two or three times a year. One
of the proposals it is currently looking at is this question of
setting out standards of care for the investigation and management
of patients with occupational asthma. The answer is that it must
be a worthwhile endeavour because it is going to improve, or its
promulgation should improve, the quality of diagnosis and management
of this condition. Whether or not it will do anything to increase
the number of cases that we are aware of is really another issue
because that is all about individuals either at general practice
level or specialist level recognising that a case may be attributable
to their occupation, bringing it to attention and investigating
it appropriately. I think it has the potential to improve standards
of care; the extent to which it will increase awareness and, therefore,
increase the number of cases I am less sure about. Just as a footnote
to that, last year I chaired for the British Occupational Health
Research Foundation—a committee which published guidelines
on the prevention, diagnosis and management of occupational asthma.
These have now been incorporated into the British Thoracic Society
guidelines for the management of asthma and have been circulated
to all respiratory physicians. So I would hope that at least at
that specialist level that information is getting there already.
For this to make an impact, it is going to have to get beyond
the specialists who are currently seeing the cases.
Q295 Lord Rea: I hope so. What about
a similar document being produced for occupational allergic skin
disorders?
Dr Orton: I am not
aware of any current work that is being co-ordinated with the
HSE for that.
Q296 Lord Rea: Do you think it would
be desirable?
Dr Orton: I think
it would be desirable, absolutely.
Q297 Lord May of Oxford: This is
a question primarily I think for Professor Agius. The University
of Manchester, as I understand it, runs several schemes that collect
data involving occupational and allergenic diseases. What proportion
of the cases reported in these schemes has an allergenic basis
and how has the number changed in recent years?
Professor Agius:
My Lord Chairman, yes, his Lordship is correct, we do collect
data from a number of schemes. Historically, the schemes in their
origin were based around specialists, for example the specialists
of interest today are mainly respiratory physicians, dermatologists
and occupational physicians and, as I intimated earlier, they
reflect very much the tip of the iceberg. The shape of the tip
of the iceberg gives us very little indication of what the iceberg's
shape is like below the waterline, so we have been arguing for
a few years that we should collect data closer to the base by
getting information from GPs and, indeed, we did launch such a
scheme 18 months ago. In very round figures because the results
are preliminary, based on the information in the reports GPs give
us, out of the totality of work-related disease that they see,
about one in 10 relates to skin and the vast majority of that
is occupational contact dermatitis. The GPs are not very well
qualified to determine what proportion of that is allergic and
what proportion of it is non-allergic ie irritant. However, based
on the information that the specialists give us, and that has
already been alluded to by my colleague, Dr Orton, we would expect
a bit less than half of those to be allergic at least initially.
Then as far as respiratory disease, about one in 20 of the cases
of occupational disease that GPs report to us generally consist
of respiratory disease and the vast majority of those would be
either asthma or asthma-like syndromes, perhaps not yet fulfilling
the full definition and not yet proven by specialists. The majority
of those would have allergic features although, as my colleague,
Professor Newman Taylor, said, not all of them might fulfil all
the immune criteria. If we now look at the totality of the data
we get, but, as I said earlier, this is very much influenced by
what the specialists tell us, we get an estimated 20,000 cases
of occupational disease every year, of which about 2,500 are reported
cases from dermatologists and about 2,500 from occupational physicians.
Of the 2,500 from dermatologists it is estimated about three-quarters
of those are occupational dermatitis and 15 per cent from the
2,500 or so estimated cases from chest physicians are asthma.
If we look at occupational physicians who report a large number
of cases, probably an estimate of about 10,000 cases of all work
related disease per year, but then in them a much higher proportion
of the respiratory cases would be asthma because that tends to
temporally have quite a close relationship to work exposure. Whereas
chest physicians tend to proportionally report a majority of cases
of non-allergic diseases related to asbestos. That is the answer
in a nutshell.
Q298 Lord May of Oxford: And the
trend or the time?
Professor Agius:
As I mentioned earlier, trend is something which is difficult
to establish because there is a number of artefacts which can
explain apparent trend. We are doing our best to take account
of those artefacts. By "the artefacts" I mean changing
denominators of the number of doctors who report, who leave the
schemes, and who join them and phenomena like fatigue which doctors
tend to experience when they are expected to fill in lots of forms
and paperwork. Having taken account of those, we do get a linear
trend assumption of a reduction of about seven per cent per annum
in incidence, but that is subject to lots of caveats and we are
investigating that further. Once we have data in due course from
the GPs, then we might be able to be a little bit more certain,
or perhaps uncertain, as to how accurate that estimate of trend
is.
Q299 Lord May of Oxford: Among those
caveats, as I understand it, first of all, some of the less severe
cases do not present themselves through diagnosis. The scheme
of reporting is voluntary and so there have been suggestions that
maybe there is under-reporting, or perhaps, alternatively, biased
reporting. I wonder, beyond what you have said, whether you think
there is validity in those criticisms and, if so, what you are
doing to try to address them?
Professor Agius:
There is validity in some of those criticisms, my Lord Chairman,
indeed I have conceded some of them. Having said that, the schemes
are one or two orders of magnitude better than the statutory mechanism.
The statutory mechanism, namely RIDDOR, the Reporting of Injuries,
Diseases and Dangerous Occurrence Regulations, is, by the HSE's
own concession, at least by personal communication, "positively
misleading"—I call it negatively misleading—in
as much as they now no longer publish the results from that. On
questioning, they say they have through RIDDOR about 40 cases
of asthma per annum and 120 cases of dermatitis per annum on average
over the last few years. That in itself is one-tenth, or less
than one-tenth, of the specialist cases that we get, and that
is in itself per annum probably one-tenth of the figure if one
takes a look under the figures further, between what our GPs see
and what is then onward referred. As your Lordship has mentioned,
of course, a number of cases go under-reported. So far as the
criticisms, they all tend to suggest that if anything the data
is an under-estimate, so when in the past we have looked at the
possibility of over-reporting, duplicate reporting, between different
specialists we have found this amounts to maybe one or two percentage
points only amongst reports. Having said that, for ethical reasons,
we are not allowed access to the names, dates of birth or even
initials of the patients concerned so we cannot be dogmatic about
the extent of over-reporting. However, when we have done specialist
studies on this, the problem is not one of over-estimates, the
problem seems to be one of under-estimates because when we compare
our data with specific focused surveys in specific industries
in good epidemiological literature, then those would suggest that
the incidence is, if anything, higher than the incidence that
is reported to us.
1 AMICUS has various partnerships with industry bodies,
for example Electrical Contractors Association (ECA) and AMICUS
form the Electrical Joint Industry Board (JIB). This and our other
partnerships, have health care provisions as part of its benefits
to employees. Back
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