General guidance for appointed doctors

 
Health and Safety
                                                                                   Executive

General guidance for
appointed doctors
Role and responsibilities in statutory medical surveillance

                Introduction
                1 This guidance is for established appointed doctors engaged in statutory
                medical surveillance and registered medical practitioners considering applying
                to be appointed for this purpose. It explains the relevant legal background, the
                appointment process and governance arrangements, and responsibilities and rights
                of appointed doctors. In addition to this guidance, appointed doctors should be
                familiar with the Health and Safety Executive’s (HSE’s) appointed doctor website,
                at: www.hse.gov.uk/doctors.index.htm

                Legal background
                2 Under the Health and Safety at Work etc Act 1974, HSE’s Employment
                Medical Advisory Service (EMAS) has a wide range of duties and responsibilities.
                One of these is the periodic medical supervision of employees who work with
                specified hazards under certain conditions. These conditions are outlined in relevant
                regulations (see www.hse.gov.uk/doctors.index.htm) and, where the nature of
                the work brings employees within those regulations and requirements, monitoring
                their health is called ‘statutory medical surveillance’. This is synonymous with
                ‘occupational health surveillance’ but with additional statutory requirements.

                3 Medical surveillance can be conducted by HSE senior medical inspectors
                (SMIs), and medical inspectors (MIs) (formerly known as senior employment medical
                advisers/employment medical advisers). However, HSE can appoint registered
                medical practitioners to undertake statutory medical surveillance. This is done by
                issuing a Certificate of Appointment under the appropriate regulations. It authorises
                the appointed doctor to conduct medical surveillance under specified regulations for
                a stated period. Although appointed by HSE, appointed doctors are not employed
                by HSE. The company requiring statutory medical surveillance is responsible for
                agreeing conditions of service and payments with the appointed doctor.

                4 Your contract as an appointed doctor with an employer is, however, conditional
                on satisfying HSE requirements. You are accountable to HSE for the work you
                carry out, and are under the supervision of the SMI who issued your Certificate of
                Appointment – essentially, you are acting as their ‘deputy’. The SMI is responsible
                for ensuring that you:

                ■■ are competent to do the work;
                ■■ are supplied with the necessary guidance material and other relevant
                    information;
                ■■ carry out medical surveillance to a satisfactory standard; and
                ■■ return appropriate information, including statistical data, when requested.

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The appointment process and governance
arrangements
5 You are responsible for achieving and maintaining your own competence, as
required by the General Medical Council (GMC) (see paragraphs 22–23). In 2009,
the GMC introduced a licence to practise. This is the first step towards introduction
of a revalidation system to ensure doctors are fit to practise.

6 It is important for HSE to have appropriate governance arrangements to monitor
your competence for the specific role of an appointed doctor. This is reflected in the
procedures detailed below for new applicants and for the review of existing appointed
doctors. The procedures take account of revalidation (once fully established) and rely
primarily on paper reviews. However, under certain circumstances, a review visit to
meet the appointed doctor will be conducted by an HSE MI (see paragraph 16) – this
can take place at the relevant workplace, an HSE office, or other appropriate location.

Applying for an appointment
7 The request for a doctor to be appointed under regulations is normally initiated
by the employer/manager to whom the regulations apply. In the first instance,
the employer/manager should consider using the services of a doctor already
appointed for the relevant regulation. If such an appointed doctor is not available,
circumstances may require the employer/manager to request the assistance of
another doctor (eg a local GP or a doctor in their own occupational health service)
who will need to apply to HSE for an appointment.

8 To apply for an appointment, you must complete parts 2–4 of form
FODMS38AB.1 The employer/manager must complete part 1. In addition to the
completed application form, you must provide the following information:

■■ a copy of your CV;
■■ evidence of registration and licence to practise from the GMC;
■■ a copy of your certificate for the Diploma in Occupational Medicine as a
     minimum qualification (and evidence of specialist knowledge in hyperbaric
     medicine for an appointment under the Work in Compressed Air Regulations);
■■   a summary of your last revalidation/appraisal report (when available as part of
     the GMC revalidation system);
■■   a copy of your professional indemnity;
■■   a description of the work processes from which the need for statutory medical
     surveillance has arisen, including the nature of relevant hazards and risks;
■■   a description of the facilities where medical surveillance will be conducted (see
     paragraphs 27–28, please provide digital photographs);
■■   details of medical and administrative support available for conducting
     medical surveillance, including numbers and grades of medical, nursing and
     administrative staff;
■■   the total number of employees (male/female) in the company (confirm with the
     employer); and
■■   the total number of employees (male/female) in the company to be placed under
     medical surveillance (confirm with the employer).

9 You should send the following documentation to the HSE office that administers
appointed doctor work for your location: See ‘Further information’.

■■ a completed application form FODMS38AB; and
■■ the relevant information listed in paragraph 8.

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Role and responsibilities in statutory medical surveillance
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                                                                     Executive

10 On receipt of a full package of information, an HSE MI will assess your application.
They will decide if the appointment is necessary under the regulations and will consider
your competence, interest and experience in occupational medicine. You will be
contacted should further clarification be required. If suitable, HSE will issue you with
a Certificate of Appointment. It will also issue you with a Schedule to the certificate
containing relevant company details. Normally, the certificate is for one year in the
first instance, and during this period you would not work for more than one company
under each set of regulations you are appointed.

11 The certificate is not transferable and may be subject to certain conditions. You
are responsible for ensuring you do not work beyond the expiry date on it,
unless issued with a new certificate.

Reviewing appointments

12 To ensure ongoing competency for the role of appointed doctor, HSE will
normally review your appointment before your certificate is due to expire. If you
have more than one appointment, they will normally be reviewed simultaneously.
The standards against which you will be assessed during a review are based on
the regulation-specific guidance for appointed doctors.2-6 For all appointments, you
should apply the general administrative standards in Appendix 1.

13 When HSE notifies you that your review is due, you must submit the following
information:

■■ evidence of registration and licence to practise from the GMC;
■■ any training specific to appointed doctor work since appointment/last review,
     including copies of any certificates;
■■ any other relevant continuing professional development since appointment/last
     review (see paragraphs 22–23);
■■ a summary of your last revalidation/appraisal report (when available as part of
     the GMC revalidation system);
■■ a copy of your professional indemnity;
■■ a sample of at least five medical records (copies only, do not send original
   documents), if available, for each set of regulations under which you are
   appointed, covering both male and female employees (see paragraphs 40–42) –
   they should be marked ‘medical in confidence’ when sending by post; and
■■ a completed Review of Appointment Declaration.7

14 On receipt of a full package of information, an HSE MI will conduct a review.
You will be contacted should further clarification be required. If appropriate, HSE
will issue you with a new Certificate of Appointment for 1–5 years.

15 The SMI has the power to revoke your Certificate of Appointment. The most
likely reasons are that:

■■ your work is unsatisfactory;
■■ you fail to abide by this guidance; and/or
■■ circumstances in the workplace necessitate direct involvement by an HSE MI in
     medical surveillance.

Review visits

16 Under certain circumstances, HSE MIs will conduct a face-to-face review visit with
the appointed doctor. You will be contacted in advance if a visit is deemed necessary.
In considering the need for review visits, the following will be taken into account:

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■■ the nature of the work, including the hazard, risk and number of employees
     under medical surveillance;
■■ an unusually large or small workload (ideally, established appointed doctors
     should conduct an average of at least ten medical examinations a year to help
     maintain their competence);
■■   complaints or concerns about the appointed doctor’s performance;
■■   failure to return relevant information and statistical data as requested;
■■   failure to keep contact details of the appointed doctor or relevant companies
     up-to-date;
■■   new appointed doctors undergoing their first review;
■■   random visits to validate the performance of a sample of appointed doctors; and
■■   resources available to undertake the review visits.

Appeals

17 You may appeal against a decision:

■■ not to issue you with a Certificate of Appointment;
■■ to impose conditions on your appointment; or
■■ to revoke your Certificate of Appointment.

18 If you wish to appeal, you should submit your request within three months of
receiving formal notice of the decision. It should be accompanied by documentary
evidence in support of the appeal. The request should be sent to:

Chief Medical Adviser
Corporate Science, Engineering and Analysis Directorate
Health and Safety Executive
Redgrave Court
Merton Road
Bootle
Merseyside
L20 7HS

Complaints

19 If there is a verbal complaint made about your work as an appointed doctor,
HSE will request written confirmation. To investigate a formal, written complaint,
you may be asked to provide written comments in response. Alternatively, an HSE
MI may visit you to gather evidence on which to base their judgement.

Extending an appointment

20 Established appointed doctors can extend their appointment. To request
an appointment under the same or different regulations for a different employer,
parts 1, 2 and 4 of form FODMS38AB should be completed and sent to the HSE
office administering your appointment. An MI will decide whether the additional
appointment is necessary and may contact you to check your understanding of the
specific hazards and risks, as well as the occupational health issues on site. The
Certificate of Appointment and/or Schedule will then be updated.

Cover for absence

21 If you require short-term assistance, because of holidays or other protracted
absence, another registered medical practitioner can be given a temporary
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Role and responsibilities in statutory medical surveillance
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                                                                    Executive

appointment. You should ensure parts 3–4 of form FODMS38AB are completed by
the medical practitioner seeking the temporary appointment. You should then send
the form to the HSE office administering your appointment for consideration. An MI
will then decide whether to agree the temporary appointment.

Responsibilities of appointed doctors
Developing and maintaining competence

22 Being an appointed doctor requires you to commit time to:

■■ study and learn the guidance material;
■■ attend appropriate training and refresher courses;
■■ see the workplace to become familiar with the activities to which the regulations
     apply; and
■■ learn about the people who are under surveillance.

23 You are responsible for achieving and maintaining your own competence.
Much of the requisite knowledge can be gained from careful study of the guidance
material provided on appointment. In addition, you will be required to attend any
training relevant to your appointment and maintain and improve your standards
through continuing professional development.

Understanding your duties to employers and employees

24 You will need to understand the relationship between employer, employee and
yourself and reconcile the ethical duty of medical confidentiality with the employer’s
need to have sufficient information to discharge their legal duties. This takes time
and practice and requires actual experience and understanding of the workplace.

25 The appointed doctor has a duty of care which is the same as that in any
clinical situation, and based on the GMC’s principles of good medical practice.8
Your first responsibility is to protect the health of those under your supervision. In
carrying out statutory medical surveillance you should explain the nature of the risk
to the person you are examining, and use the examination as an opportunity for any
relevant health education. Your relationship with an employee is not the same as
that which exists between doctor and patient. This is because you have additional
duties to the employer and to HSE.

26 For employers to discharge their legal duties, they need to have sufficient
information to enable them to assess whether or not protective measures in the
workplace are adequate and health risks are being properly controlled. As an
appointed doctor, you might be able to help by using your knowledge and experience
of occupational health and hygiene and/or the tests on the employer’s workforce
that you have carried out. This can lead to a conflict between a doctor’s duty of
confidentiality to the employee and the employer’s need to be aware of any emerging
problems. In practice, this is a perceived, rather than an actual, problem. Workers
under medical surveillance may be prepared for their employer to be informed of the
outcome of examinations and test results. Indeed, in some circumstances, this is a
condition of employment. However, you must obtain written, informed consent from
each employee before disclosing information beyond that which is statutorily required.
In some situations, you may provide the company with a list of anonymised results.
At the very least, if consent is not given, you should indicate in writing whether
the individual is fit to continue their normal work activities. Any trade union safety
representatives within the company also have a right to this information.
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Role and responsibilities in statutory medical surveillance
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Performing medical surveillance

Facilities

27 Facilities for medical examinations must be fit-for-purpose. Where examinations
are carried out on factory premises, the employer has a duty to provide adequate
facilities. Some work activities, such as asbestos removal and demolition work,
are peripatetic in nature. It may then be necessary to conduct examinations at a
central point, such as the company’s offices or doctor’s surgery. However, you
may need to visit workplaces from time to time in order to view the work activities
and conditions, as well as welfare facilities – including washing facilities, toilets and
showers (eg for lead workers).

28 You should not be persuaded to carry out medical examinations in sub-
standard accommodation. Appropriate accommodation should provide:

■■ a safe environment for conducting examinations;
■■ an environment which safeguards the privacy of the worker during examination;
■■ any equipment (which should be appropriately maintained) and furnishings
     necessary for conducting examinations;
■■ acceptable levels of hygiene;
■■ adequate heating and ventilation; and
■■ hand-washing facilities.

Medical examinations and investigations

29 You must see the employees covered by regulations at appropriate intervals
as defined in relevant guidance and carry out the necessary medical examination.
The employer has a duty to identify those workers to be placed under medical
surveillance and ensure they present themselves for examination. You should make
sure this duty is understood by the employer at the time of your appointment.
There should be management arrangements in place to ensure you become aware
of new employees. In addition, there should be arrangements for investigating any
abnormal findings arising from medical surveillance.

30 You must ensure all relevant clinical tests are performed. Blood and urine
samples are usually taken at the time of the examination. Parts of medical
examinations can be delegated to suitably trained and competent nurses. However,
you must still see workers and, where relevant, assess their fitness to continue
work as guided by the relevant regulations, Approved Codes of Practice (ACoPs)
and guidance.

31 Any blood and urine samples should be analysed at a laboratory contracted to
the employer, who will pay for this service. The carriage of such samples in the mail
is subject to strict conditions. Radiological examinations, if indicated, are usually
carried out at a local hospital by appropriate arrangement. The National Health
Service does not provide them for free. There is a concessionary charge for work
in connection with statutory examinations. Again, the employer is responsible for
payment. Results of all tests should be sent directly to you for interpretation.

32 You should remember that statutory medical surveillance may cause
considerable disruption to production. You should be flexible, punctual and efficient.
If an employer or employee cannot be persuaded to co-operate with HSE advice
and requirements, or if there is a serious breach of regulations, health and safety
inspectors, in association with MIs, will decide what enforcement/prosecution
action is necessary. If you experience any difficulties in carrying out your work as an
appointed doctor, you should immediately inform the MI, who will enlist the help of
a health and safety inspector, if necessary.

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Role and responsibilities in statutory medical surveillance
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                                                                      Executive

Fitness/unfitness to continue work

33 Under certain regulations, you will need to provide an opinion on an employee’s
fitness or unfitness to continue in that particular work. In these cases, an unfit
worker must be removed from further exposure to the responsible hazard until
you certify them as fit. The individual may have to be suspended from work
entirely, or may be able to continue in employment subject to certain conditions
(eg employment in another section away from the hazard). Remember that
unfitness relates only to those work activities that come within the regulations.

34 You must notify management in writing, normally using a Certificate of
Unfitness. The suspension will remain in force until you are satisfied the employee
is fit. If this is by entry in the health record (see paragraph 39), it must be drawn to
the attention of the employer. The employee must also be notified or given a copy
of the Certificate of Unfitness. Where a Certificate of Unfitness is issued, it must be
signed for, if delivered by hand. If sent by post, you must use Recorded Delivery
with Advice of Receipt. This ensures an acknowledgement, signed by the recipient,
is returned by the Post Office to the sender.

35 In addition, you must immediately notify the MI, in writing (usually by a copy
of the Certificate of Unfitness), of any worker who is suspended under regulations
or is subject to limiting conditions. You must also notify the MI when the individual
is allowed to resume work. It is good practice to inform the MI of unsatisfactory
health or hygiene trends in the workplace, even if they do not result in the need to
suspend workers from exposure to the hazard.

36 Employees suspended from work on health grounds, under relevant
regulations, are entitled to medical suspension pay. They should not claim industrial
injury or similar benefits.

37 You should be aware that employees have the right to ask for a review of a
decision to suspend them from work on health grounds. You may be required to
justify any decision relating to a suspension.

38 If you identify an ill-health outcome, with the consent of the employee, you
should notify their GP.

Statutory health record

39 You must inform the employer in writing, usually by an entry in the health
record, that the employee has been examined under regulations. The statutory
health record may include other non-medical data, such as results of environmental
monitoring, but must include at least the details required by the regulations and/
or ACoP. The health record must be kept for at least the period specified in the
regulations or ACoP. You should let the MI know if any problems arise regarding
retention of health records, for example, where a company ceases to trade.

Medical records

40 Your clinical records must be kept up-to-date and include details of medical
examinations, tests and any survey you have undertaken in connection with your
duties. You must make sufficient notes, whether in questionnaire form or hand-
written, to demonstrate a reasonable standard of care. You are responsible for the
safe keeping of all medical records, including medical notes, investigation results,
X-ray film and/or reports etc. They may be kept on paper or on computer but they
must be available for examination by an MI.

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41 It is your responsibility to agree with the employer how and where they will be kept,
and how their security will be guaranteed. When taking up your post, it is therefore
essential you obtain written agreement from the company that all such records will be
regarded as ‘medical in confidence’. Access to the information they contain must be
restricted in accordance with well-established principles of medical ethics governing
occupational health practice.9 You must obtain written, informed consent from the
individual before disclosing medical information to their employer or GP.

42 You must not destroy clinical records without the authority of HSE. The
maintenance of adequate records is essential as they:

■■ provide proof you are discharging your duties;
■■ are important in conjunction with the statutory health record which the employer
     has a duty to keep;
■■ may be central in any subsequent investigations for civil litigation; and
■■ form the basis for periodic returns that you must make to HSE (see paragraph 43).

Completing statistical returns

43 It is a condition of your appointment that you respond promptly to requests for
information on your activities as an appointed doctor. For example, periodically, the
Health and Safety Laboratory will provide a form (MS21) for recording information
on the number of statutory medical examinations you conduct. Once completed,
you should retain a copy of the form.

Rights of appointed doctors
44 As an appointed doctor, your authority is implicitly supported by HSE on behalf
of which you carry out statutory medical surveillance. Unlike an MI, you have no
legal powers, however, you do have certain rights which are essential to carry out
the work effectively.

Access to the workplace

45 You have a right of access to the workplace at any reasonable time. In this
context, ‘reasonable time’ means any time, day or night, when those under your
supervision are at work. This is necessary for you to familiarise yourself with work
activities and conditions.

You should:

■■   visit by prior arrangement with management;
■■   be accompanied by a responsible person (eg a foreman or supervisor);
■■   obey local safety rules; and
■■   wear any protective equipment provided.

You should not:

■■ expose yourself to unnecessary risk; or
■■ enter any prohibited area such as an asbestos stripping enclosure.

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Role and responsibilities in statutory medical surveillance
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Access to employees

46 You must be given access to employees to carry out medical examinations and
necessary investigations at such intervals as you consider necessary. This should
be during employees’ working hours and at the employer’s expense.

Employee compliance

47 You have the right to require employees to submit to appropriate medical
examinations and provide you with relevant information to assess their fitness. This
includes any necessary clinical investigations. If an employee will not let you take
essential samples, you cannot certify them as fit to continue working in activities
that fall within the regulations. Even where there is no requirement under the
regulations to certify fitness, the medical examination is a statutory requirement.
You should make this clear to the employee. In such cases, you should notify the
employer in writing. If the situation remains unresolved, you must notify the MI.

Suspension of employees from work
48 Under certain regulations, you have the right to suspend employees from work
that exposes them to specified hazards, if you believe such exposure would be
prejudicial to their health. In exercising this right, you must follow the procedures
outlined in paragraphs 33–38.

Remuneration

49 You have a right to be paid for conducting statutory medical surveillance. The
company using your services is responsible for paying your fees as well as the cost
of any clinical investigations. HSE can accept no responsibility for these matters.

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Role and responsibilities in statutory medical surveillance
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                                                                    Executive

Appendix 1 General administrative standards
1 Appropriate management systems must be in place so the appointed
doctor can discuss new employees and the timing of repeat assessments with
management.

2 There must be management procedures to investigate abnormal results of
surveillance.

3    There must be a medical record for each individual under surveillance.

4    All medical records must contain the following:

■■   name of the individual;
■■   employee’s current address;
■■   National Insurance number;
■■   date of birth;
■■   GP’s name and address;
■■   clinical history – past medical, occupational and exposure history, and past and
     current smoking status;
■■   dates of surveillance;
■■   results of surveillance;
■■   action taken; and, where relevant,
■■   record of informed consent to disclose results to the employer and ill health
     outcomes to the GP.

5    There must be evidence that medical records are kept securely.

6    The appointed doctor must notify HSE of a change of contact details.

7 The appointed doctor must notify HSE of changes in GMC registration/
licensing.

8 Where an appointed doctor wishes to be appointed to additional companies,
the details of the new company must be sent to HSE using form FODMS38AB.
Subsequently, HSE should be notified of any change in circumstances, including
cessation of risk.

9 The appointed doctor must make an application for temporary appointment of
a colleague to ensure that medical examinations under statute can be carried out
during temporary absence of the usual appointed doctor.

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Role and responsibilities in statutory medical surveillance
Health and Safety
                                                                   Executive

References
1 Form FODMS38AB is available at www.hse.gov.uk/forms/health/fodms38ab.pdf

2 Guidance for appointed doctors on the Ionising Radiations Regulations 1999
HSE 2011 www.hse.gov.uk/pubns/ms33.pdf

3 Guidance notes for appointed doctors on the Control of Lead at Work
Regulations 2002. In: Control of lead at work. Control of Lead at Work Regulations
2002. Approved Code of Practice and guidance (Appendix 5) L132 (Third edition)
HSE Books 2002 ISBN 978 0 7176 2565 9 www.hse.gov.uk/pubns/priced/l132.pdf

4 Guidance for appointed doctors on the Control of Asbestos Regulations 2006
HSE 2011 www.hse.gov.uk/pubns/ms31.pdf

5 Guidance for appointed doctors on the Control of Substances Hazardous to
Health Regulations 2002 (as amended) HSE 2011 www.hse.gov.uk/pubns/ms32.pdf

6 Guidance for appointed doctors on the Work in Compressed Air Regulations 1996
is available from HSE offices administering appointed doctor work

7 Review of Appointment Declaration can be found on HSE’s appointed doctor
website www.hse.gov.uk/doctors/index.htm

8 Guidance for doctors. Good Medical Practice. General Medical Council 2006
ISBN 978 0 901458 24 7 www.gmc-uk.org/guidance/good_medical_practice.asp

9 Guidance on Ethics for Occupational Physicians (Sixth edition). Faculty of
Occupational Medicine of the Royal College of Physicians 2006 ISBN 1860162800

Further information
Additional information for appointed doctors can be found on HSE’s appointed
doctor website at www.hse.gov.uk/doctors/index.htm. This includes relevant
regulations, guidance notes, forms and a list of HSE offices administering appointed
doctor work.

For information about health and safety, or to report inconsistencies or inaccuracies
in this guidance, visit www.hse.gov.uk/. You can view HSE guidance online and
order priced publications from the website. HSE priced publications are also
available from bookshops.

This document is available at: www.hse.gov.uk/pubns/ms30.pdf.

© Crown copyright This publication may be freely reproduced, except for
advertising, endorsement or commercial purposes. First published 04/11. Please
acknowledge the source as HSE.

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