Statutory Sick Pay (SSP) or equivalent 1 \200 Payable by employer for spells of incapacit y <28wks \200 Certi \201 cated according to \201 tness for own occupation < 7 days, self-certi \201 cate SC1, SC2, or employers own form \200 >7 days, Med 3 (Stat ement of Fitness for Work) provided by GP or hospital doctor for out-patients or Med 10 provided by hospital doctor for hospital in-p atients. Includes advice on rehabilitation. State bene \201 ts 1 Employment and Support Allowance (ESA) \200 Entitlement depends on National Insurance (NI) contributions \200 Those who have not paid suf \201 cient NI, ma y qualify for income-based ESA depending on income and capital State bene \201 ts are subject to an assessment of work capability. Work Capability Assess ment (WCA) \200 Eligible when SSP ended, self-employed or unemployed \200 Assessment by a health professional +/ \200\223 medical assessment \200 Carried out during the \201 rst 13wks after application assessment of limited capability for work \200\224the focus is on what work activities the patient can carry out. The applicant has access to a personal adviser, training and condition management and is expected to move towards a return to work assessment of limited capability for work-related activity \200\224for the most severely affected, who are not expected to prepare for work GP no longer required to certi \201 cate if ESA awarded \200 The WCA assesses: the impact of health on daily life \200 the patient \200\231s view of the future from a h ealth and work perspective \200 activities the patient enjoys or would like to develop to help them move into work the support the patient feels they need to move into work Following WCA, support for those who are capable of work-related activities: \200 condition management program \200 expert health advice \200 workshop s on health topics, e.g. coping with pain, positive mood management, motivational support, preparing for work. 1 The newly published sickness absence review (21.11.11) proposes changes to the sickness a bsence and bene \201 ts system which will be subject to consideration and response by the UK gov- ernment during 2012. 20_Smedley_Chap20.indd 400 1/2/2013 12:31:51 PM SICKNESS BENEFITS 401 Self certifica- tion(cid:2)7days days Illness or injury, and off work SSP Assessment by GP or hospital doctor Med 3, Med 10 >7 days Support Group (not required to return to work) Work Capability Assessment by DWP ESA Work-related activity Group Specific support provided RETURN TO WORK Benefits Certification Fig 20.1 Summary of the process for assessing eligibility for bene \201 ts in relation to \201 tness for work 1 Further information and guidance For Occupational Health. Available at: M http://www.dwp.go v.uk/docs/ \201 tnote-occupational-hea lth-guide.pdf For GPs. Available at: M http://www.dwp.gov.uk/docs/esa-gp-lea \202 et.pdf; Also available at: M http:// www.dwp.gov.uk/docs/gp-bene \201 t-guide.pdf; Also available at: M http://w ww.dwp.gov.uk/docs/ \201 tnote-gp-guide.pdf 20_Smedley_Chap20.indd 401 1/2/2013 12:31:51 PM CHAPTER 20 Sickness absence and rehabilitation 402 Sickness absence: general principles De \201 nition and size of the problem Sickness absen ce is de \201 ned as any absence from work attributed to illness or injury, and accepted a s such by the employer. It gives rise to signi \201 cant costs for all organizations. The Confederation of British Industry (CBI) estimate that in the UK, nearly 190 million working days were lost due to sickness in 2010, at a cost of 17bn. 1 That survey found absence l evels of 8.1 days per public sector employee and 5.9 days per private sector employee. Howe ver, evidence from HSE suggests that differences between the public and private sectors are small, and may be partly explained by under-reporting in small private sector organization s. (cid:2) Estimates of the proportion of sickness absence actually due to non-medical reas ons vary widely ( 10% up to 30%) and should be viewed with great caution. Determining what proportion of sickness absence is not genuine is, for obvious reasons, very dif \201 cult. Risk factors for sickness absence Absence rates tend to be higher: \200 Among women compa red with men \200 In older workers (total days of absence), although young workers have more spells of short-term absence In larger compared with smaller organizations \200 In the public sector compared to priva te industry (but note that the public sector employs more women and older workers and comprises mostly large organizations ). Patterns of sickness absence \200 Short-term: frequent short-term absence is most commonly due to minor unrelated self-limiting illness o r injury, although it can indicate chronic underlying ill health however, it can mask non-medical absence Long-term: almost invariably due to signi \201 cant medium- to long-term ill health Because of this general difference in the nature of short- and long-term absence, the broad approach to management also differs. See b p. 404, Short-term sickness absence; b p. 406, Long-term sickness absence). Measurement of sickness absence Simply counting hours or days lost as a proportion of total days worked by all staff ( crude absence rate ) may be misleading and does not show whethe r the main issue is short or long term absence. \200 Frequency rate: shows the mean numbe r of absences per worker as a percentage. (No. spells of absence in the period/No. employees) \227 100 1 CBI-P \201 zer Absence Survey 2011. 20_Smedley_Chap20.indd 402 1/2/2013 12:31:51 PM SICKNESS ABSENCE: GENERAL PRINCIPLES 403 Lost time rate: measures the mean number of working days lost as a percentage of total working days. [Total no. working days lost due to absence in a year/(Working days in year \227 total no. employees)] \227 100 The lost time rate can be calculated across the company or for speci \201 c business units or by trade/profession, thus highlighting \200\230hotspots \200\231 of poor attendance. T his calculation can also be made for lost hours rather than lost days \200\224useful for em ployers with a large number of part-time staff. Bradford score S 2 \227 D Where S is the number of spells of absence and D is the number of days of absence in a give n time period (e.g. rolling 52-wk interval). The Bradford score is calculated for each worker individually. It high- lights the disrupti on caused by repeated short-term absence by weighting the number of episodes (or spells) of absence. For example, \200 Twelve 1-day absences: 12 \227 12 \227 12 = 1728 \200 One 12-day absence: 1 \227 1 \227 12 = 12 \200 Three 1-day absences: 3 \227 3 \227 3 = 2 7 \200 One 3-day absence: 1 \227 1 \227 3 = 3 The Bradford score may be used to set a t hreshold for case management so that consistency in approach between employees can be demon strated. The threshold score can be based on the extreme of the distribution (upper 5 \200 \22310% of all scores) rather than an absolute total score, avoiding the perception of a \200\230safe score \200\231 among employees. This measure tends to be used in organizations where most staff works shifts and short-term absence is more disruptive than long-term abs ence. Further information HSE (2005). Survey of workplace absence sickness and (ill) health (SWASH) . Available at: M http:// www.hse.gov.uk/sicknessabsence/ CBI absence survey 2011 M http://www.cbi.org.uk/media/955604/2011.05-healthy_returns_-_ absence_and_workplace_health_survey_2011.pdf 20_Smedley_Chap20.indd 403 1/2/2013 12:31:51 PM CHAPTER 20 Sickness absence and rehabilitation 404 Short-term sickness absence 2 Frequent short-term term absence is usually regarded as a man agement issue. The input from OH professionals generally has a different focus compared wit h long-term absence. There is no accepted de \201 nition of short-term sickness absence \200\224the National In stitute for Health and Clinical Excellence (NICE) de \201 ne it as any absence of less tha n 28 days and recurrent short-term absence as more than one episode of short \200\223term a bsence, each episode lasting less than 28 days. Factors that affect short-term absence Medical \200 Self-limiting illness \200 Poor con trol of chronic medical conditions: inadequate treatment \200 poor self-management \200 side-effects of treatment Substance misuse: \200 alcohol misuse \200 drug misuse Epidemics. Organizational \200 Sick pay \200 Personnel policies \200 Poor working con ditions: long or unsociable hours \200 boring or unpleasant work \200 poor training or supervisi on \200 shift work Interpersonal dif \201 culties in the workplace: \200 between manager or colleagues \200 (cid:2) suspect bullying if absences mirror the supervisor \200\231s shifts Poor labor relations \200 Change, e.g. redundancies. Psychosocial and cultural \200 Ret irement age \200 Local unemployment \200 Domestic factors: \200 childcare \200 elde rly relatives \200 sick or disabled relatives \200 intimate partner violence \200\224th e British Crime Survey found that 20% of employed female victims and 6% of employed male vi ctims took time off work and 2% of both sexes lost their job as a result Poor work motivation: \200 young people \200 temporary workers 20_Smedley_Chap20.indd 404 1/2/2013 12:31:51 PM SHORT-TERM SICKNESS ABSENCE 405 Social and cultural factors: sporting events \200 appointments with hairdressers, tradesmen, etc. \200 holidays \200 cultural, e.g. a widespread belief that employees are entitled to a level of sick leave, to be used as additional holiday. Role of occupational health When an employee with repeated short-term absence is referred, the main purpose is to ensure that medical issues are properly taken into account by the em ployer in managing the absence pattern. The role of OH is to identify medical reasons why t he employee \200\231s absence pattern might deviate from the average for the organization. \200 In the absence of medical factors, the OH practitioner should give a clear message t hat no underlying chronic or recurrent illness explains the excess absence. This is the cas e when absences are a collection of minor self-limiting illness that are no more likely to occur in the referred employee than in any other. It can be helpful to add that there is no medical intervention that would have an important impact on the pattern of absence If an underlying health problem makes the employee more susceptible to short-term absence, the OH practitioner should communicate the susceptibility (but not necessarily the diagnosi s) clearly. It is helpful to comment on the likely future pattern of absence (taking into a ccount any medical intervention), and how much excess absence might reasonably be expected In the case of recurrent short-term sickness absence due to a single medical condition then the same approach as NICE recommends for the management of long-term sickness absence (NIC E PH19) is appropriate. (See b p. 406, Long-term sickness absence). Interacting psychosocial factors \200 The division between medical and psychosocial is ra ther more blurred than implied by the checklist here. Factors such as dif \201 culties at home and work often impact on wellbeing even if they do not cause a well-de \201 ned \200 \230illness \200\231 The OH adviser should facilitate the raising of any workplace issues that might be in \202 uencing absence, so that these can be addressed \200 It can also be helpful to highlight any major domestic problems so that the manager and HR can at least take these into account, offering support or adaptatio ns where this is appropriate. However, this must be done sensitively, and with the employee \200\231s consent. Further information NICE (2009). Management of long-term sickness absence and incapacity fo r work , PH19. Available at: M http://www.nice.org.uk/PH19 20_Smedley_Chap20.indd 405 1/2/2013 12:31:51 PM CHAPTER 20 Sickness absence and rehabilitation 406 Long-term sickness absence Absences > 28 days are usually due to signi \201 cant illness/i njury. OH input aims to enable rehabilitation where possible: ill-health retirement is a la st resort. The most common causes of long-term absence are: \200 Mental illness (stress, anxiety/depression) \200 Musculoskeletal disorders (MSDs) (low back pain, osteoarthritis) . NICE guidance on sickness absence management (PH19) NICE guidance on sickness absence man agement advises early contact with absent employees, ideally at 2 \200\2236wks absence, and suggests a tiered response. Initial enquiries Employers should task someone impartial to make initial enquiries to: \200 Identify reasons for sickness and barriers to returning to work \200 Discuss return to work options and agree any action needed \200 If necessary appoint a case worker to c ontact the worker, agree management plan and co-ordinate interventions. Detailed assessment If needed, arrange assessment by a relevant specialist \200\224may incl ude: \200 Specialist advice on diagnosis and treatment \200 Use of a screening tool \200 A combined interview and work assessment \200 Develop a return-to-work plan, and if needed, interventions. Level of interventions (if needed) In addition to usual treatment c onsider: \200 \200\230Light \200\231 interventions for workers likely to return to work \200 \200\230Intensive \200\231 interventions for those unlikely to return to work (e.g. CBT or physiotherapy). Occupational health assessment Process frequent and active case management, clinical assess ment +/ \200\223 dis- cussion with manager or HR +/ \200\223 workplace visit. Purpose \200 Establish the nature of the underlying medical condition \200 In a minority of cases it is useful to obtain a report from the GP, hospital doctor, or other specialist (physiotherapist or psychologist) Facilitate optimal medical management: some employers provide treatment or fund private health care \200 careful communication w ith the GP essential, as is written consent from employee. If medical intervention is arran ged, inform GP Carry out a functional assessment. This is crucial to the OH management of long-term absence, as it informs rehabilitation (see Box 20.1) Identify precipitating or exacerbating factors at work \200 Explore and address psychosoc ial factors (see Box 20.2), Facilitation of self-directed goal-setting and use of positivel y in \202 uencing consultation skills (e.g. motivational interviewing) by the OH team can be helpful. 20_Smedley_Chap20.indd 406 1/2/2013 12:31:52 PM LONG-TERM SICKNESS ABSENCE 407 Output Written report to management +/ \200\223 human resources detailing: \200 Prognosis for work including likely duration of absence and likelihood of recurrent absence in the future Need for adjustments to work, where relevant: to facilitate rehabilitation. Agree a rehabilitation program with employer/employee. It is sometimes helpful to share the rehabilitation plan with the G P (with the employee \200\231s consent) to reduce the risk of recurrence Outline the plan for review (clinical +/ \200\223 workplace) \200 Do not disclose medical details to the employer, except where: required by law (e.g. RIDDOR), but obtain employee \200\231s consent \200 disclosure (wit h consent) to facilitate the employer \200\231s/co-workers \200\231 understanding of impact of condition, e.g. if an insulin-dependent diabetic is at high risk of hypoglycaemic attac ks, informed intervention by colleagues is important the minimum necessary information should be disclosed. The worker must know what will be disclosed and to whom \200 Advise manager if the Equality A ct is likely to apply. Only an employment tribunal can decide if the de \201 nition of disability is actually ful \201 l led Identify and try to resolve disparity between sources of medical advice. In the event of unresolved disparity, the employer can take their occupational phys ician \200\231s advice if their expertise is the most appropriate. Box 20.1 Functional assessment Record symptoms (severity and duration), but the emphasis sh ould be on functional capacity . A useful checklist includes: \200 Generic capabilities: duration of sitting, standing, walking, reading/ concentrating. Ability to bend, lift/carry, reach up. \200\230Down time \200\231: time spe nt in bed during the day Day-to-day activities: washing/dressing, cooking, housework, gardening, driving, shopping, computer use, sport and social activity Work activities: enquiry tailored to speci \201 c job tasks. (cid:2) This is not intended to be a complete list. Box 20.2 Psychosocial factors Successful return to work dependent on employee \200\231s mot ivation/beliefs about health/work \200\224belief is that they will never again be \201 t for work means they are unlikely to return to work, irrespective of medical condi- tion. Us eful to assess such beliefs at an early stage. Further information NICE (2009). Management of long-term sickness absence and incapacity fo r work , PH19. Available at: M http://www.nice.org.uk/PH19 20_Smedley_Chap20.indd 407 1/2/2013 12:31:52 PM CHAPTER 20 Sickness absence and rehabilitation 408 Evidence-based recovery times Increasingly, evidence-based guideline material is being used to promote consistency of medical advice in the assessment of \201 tness for work. Table 20.2 is based on average recovery times for common surgical proce- dures. It is not intend ed to be an exhaustive list, or to be used in \202 exibly. However, it does provide a \200\230rule of thumb \200\231 to be adjusted according to the clinical and job details of individual cases. Further information and guidance Royal College of Surgeons. (2012). Get well soon: helping you make a speedy recovery after your surgery . Available at: M http://www.rcseng.ac.uk/patient_information/get-well-soon at: M h ttp://www.rcog.org.uk/recovering-well/ Royal College of Obstetricians and Gynecologists.(2012). Return to \201 tness: recovering well . Available 20_Smedley_Chap20.indd 408 1/2/2013 12:31:52 PM EVIDENCE-BASED RECOVERY TIMES 409 Table 20.2 List of expected time off work for uncomplicated procedures Operation Minimum expected (wks) Maximum expected if no complications (wks) Angiography/angioplasty <1 4 Appendectomy 1 3 Arthroscopy <1 <1 Cataract surgery 2 4 Cholecystectomy 2 5 Colposcopy +/ \200\223 cautery <1 <1 CABG or valve surgery 4 8 Cystoscopy <1 <1 D&C, ERPC, or TOP <1 <1 Femoro-popliteal grafts 4 12 Haemorrhoid banding <1 <1 Haemorrhoidectomy 3 6 Hysterectomy 3 7 Inguinal or femoral hernia 1 3 Laparoscopy +/ \200\223 sterilization <1 <1 Laparotomy 6 12 Mastectomy 2 6 Pacemaker insertion <1 <1 Pilonidal sinus ** <1 <1 Retinal detachment <1 Avoid heavy work, lifelong Total hip or knee replacement 12 26 TURP 3 6 Vasectomy <1 <1 Key: CABG, coronary artery bypass graft; D&C, dilatation and curettage; ERPC, evacuation of retained products of conception; TOP, termination of pregnancy; TURP, trans-urethral resec tion of prostate. Taken from table 8.2 (p. 199), Chantal Simon et al (2005). Oxford Handboo k of General Practice 2e, with kind permission of Oxford University Press. ** If time off f or dressings is allowed. 20_Smedley_Chap20.indd 409 1/2/2013 12:31:52 PM CHAPTER 20 Sickness absence and rehabilitation 410 Rehabilitation and disability services A range of facilitative services are available for d isabled people who are trying to maintain or regain employment: \200 These are provided b y a variety of organizations including charitable trusts and government-funded departments These resources can be accessed by employees themselves, but OH departments can usefully signpost routes of contact The services include provision of \201 nancial support for employers of disabled people, and provision of sheltered employment opportunities for those who are out of work because of disability. Jobcentre plus This government agency is part of the DWP. It aims to support people of work ing age, who are on state bene \201 ts, in overcoming barriers to gainful employment. Furt her information is available at M http://www. dwp.gov.uk/jobcentreplus/ M http://www.direct .gov.uk/en/Employment/ Jobseekers/ContactJobcentrePlus/DG_186347 Access to work scheme (AtW): Advice and grants towards additional employment costs. For new employ- ees, the grant is up to 100% of the approved costs. For existing employees, the gr ant is up to 100% of the approved costs up to 10 000 depending on the size of the organiz ation. Larger employers are expected to share a proportion of the costs. M http://www.direc t.gov.uk/en/DisabledPeople/ Employmentsupport/WorkSchemesAndProgrammes/DG_4000347 The range of services includes the following: Support at interview \200 Special equipment, e.g. induction loops for hearing impaired in dividuals \200 Adaptations to premises (e.g. improving wheelchair access) \200 Help wit h travel costs if disabled employees cannot use public transportation. Work Choice: special advice and support for disabled people to \201 nd or stay in work an d whose needs cannot be met by other Jobcentre plus services. Residential training: for dis abled adults. Adaptations for disabled drivers A network of independent regional mobility c enters in the UK, offering advice and assessment for drivers with medical problems. M http: //www. mobility-centers.org.uk/ Information technology (IT) and disability Ability Net is a charitable organization that provides free information and advice, individual assessment o f technology needs, the supply of assistive technology with free support, a program of awar eness education, and consultancy for employers on system and workstation adaptations and we b accessibility. M http://www.abilitynet.org.uk/ 20_Smedley_Chap20.indd 410 1/2/2013 12:31:52 PM REHABILITATION AND DISABILITY SERVICES 411 Disability in education/ universities Under the Equality Act 2010, universities and other e ducational estab- lishments are required to make adjustments for disabled students. Many un iversities have well-de \201 ned resources for supporting disabled students, and these are often a source of useful information. M http://www.cam. ac.uk/cambuniv/disability/universi ty/trainingdb/ Charities and organizations that support disabled people in work \200 The Shaw Trust. Available at: M http://www.shaw-trust.org.uk/ \200 Remploy. Available at: M h ttp://www.remploy.co.uk/ \200 Scope. Available at: M http://www.scope.org.uk/ 20_Smedley_Chap20.indd 411 1/2/2013 12:31:52 PM CHAPTER 20 Sickness absence and rehabilitation 412 Ill-health retirement Ill-health retirement (IHR) is not a decision to take lightly. Howeve r, if an individual will never again be \201 t for his/her designated post, no suit- able alternative employment is available, and he/she ful \201 ls pension scheme criteria, furt her delay in recommending ill-health retirement is undesirable and unethical. Factors to co nsider in assessing whether an individual is eligible include the following. Medical factors \200 Diagnosis : seek medical reports and/or interview and examine the applicant in person. Seek consent for up-to-date medical reports from the individual \200 \231s doctors: \200 a GP \200\231s report is helpful in giving an overview of an employee \200\231s health including psychosocial factors a specialist can best address issues around prognosis and treatment options in cases of doubt, an independent medical report for occupational purposes may be helpful, and some Pensions Boards require independent reports as a matter o f routine Duration of illness : a reasonable period should have elapsed to allow for appropriate treatment to be instituted and its effect assessed. As a general guide, it should be possible to make a decision after 6 \200\2239mths of incapacity Treatment : has a range of treatment options been explored? This does not mean all available treatments, but several options should be explored before concl uding that a condition is permanent Permanence : usually interpreted as meaning that the illness will persist until the normal retirement age. Some schemes require that the condition should be permanen t before IHR will be approved. Others apply the less stringent criterion that the condition is expected to persist for the \200\230foreseeable future \200\231. However, \200\230for eseeable future \200\231 can be dif \201 cult to de \201 ne, and discussion with the othe r doctors advising within a particular pension scheme is desirable in order to maintain con sistency. Permanence is easier to demonstrate in those close to normal retirement age Comorbidity : where an individual has several conditions, these may make the difference bet ween the employee coping with his/her designated post and being un \201 t Ageing : an employee with a \201 xed de \201 cit (e.g. polio) may \201 nd that, althou gh the condition itself has not changed, he/she is no longer able to cope with work owing t o age-related loss of physiological reserve. However, be absolutely sure that you can demon strate a clear deterioration in a function that is a recognized feature of the disease \200 Sickness absence : a pattern of increasing sickness absence (frequency, duration) may indicate that an employee is no longer able to offer regular effective service. In that ca se, IHR may be appropriate if the condition is permanent. An individual applying for IHR is , by de \201 nition, un \201 t for work and should be on sick leave 20_Smedley_Chap20.indd 412 1/2/2013 12:31:52 PM ILL-HEALTH RETIREMENT 413 Reasonable adjustments : (see b p. 410, Rehabilitation and disability services). IHR is a last resort, only after adjustments and redeployment have been carefull y considered Limited life expectancy : terminally ill employees may have their application fast-tracked by the pension scheme. Depending on scheme rules, it may be \201 nancially advantageous to some employees to remain in employment until death (death in ser vice) rather than seek IHR. Some schemes offer an enhanced lump sum and commuted pension if an individual, usually without dependents, has limited life expectancy. Non-medical factors \200 Organizational pressures : requests to retire on health grounds may increase at times of reorganization or downsizing for one of two reasons: \200 IHR ma y be \201 nancially more attractive than redundancy to some long-serving staff some staff may genuinely be un \201 t, but have been \200\230carried \200\231 by colleagues. Restructuring may reveal such problems Operational pressures : managers may try to remove incompetent staff by persuading them to retire on health grounds; this pressure should be resisted Financial pressures : once occupational sick pay has ceased, both employer and employee may be keen to seek IHR rapidly. Financial pressures are not in thems elves a reason to advise IHR. Pension scheme membership \200 Retirement is distinguished from termination of employment on medical grounds by the payment of a \200\230pension \200\231 \200 It is not usually a re quirement of employment that a worker be a member of a company pension scheme or indeed any scheme. 2 Do not assume that an employee is a pension scheme member: check. Scheme rules \200 Pension scheme rules : these vary and it is imperative to be aware of t he relevant scheme \200\231s rules before offering an opinion Length of service : many schemes will not award a pension to members with short service (<2yrs); instead contributions are refunded Approved doctors : some schemes will only accept a recommendation for IHR from a quali \201 ed occupational physician. Others restrict this role to doctors on an approved list, e .g. an organization \200\231s chief medical adviser Added years : some schemes offer \200\230added years \200\231 of reckonable service where a member is retired on health grounds. This increases the value of the \201 nal pen sion, but can have unintended consequences where employees select the \201 nancially opti mum time for ill health retirement \200 Higher/lower tier: some schemes have two tiers \200\224retirees un \201 t for their job, but \201 t for other work ( lower tier retiral ) receive a smaller pension than those permanently un \201 t for all employment ( higher t ier). 20_Smedley_Chap20.indd 413 1/2/2013 12:31:52 PM This page intentionally left blank 415 Chapter 21 Principles of risk assessment and risk management Introduction and terminology 416 Conceptual model 417 General principles 418 Sources of sci enti \201 c evidence and uncertainty 420 Risk communication and perception 421 21_Smedley_Chap21.indd 415 1/2/2013 12:33:16 PM CHAPTER 21 Risk assessment and risk management 416 Introduction and terminology Need and context Decisions in OH often entail a choice between two or more options, the comparative merits of which are not immediately obvious. The deci sion may be for an individual (e.g. whether to ground a pilot because of a health problem), for the whole of a workforce (e.g. whether to immunize HCWs against smallpox), or at a soc ietal level (e.g. whether to permit the use of a pesticide). Risk management is the process by which decisions of this sort are made, following an assessment of the risks and bene \201 ts associated with each option. Depending on the nature of the decision, the process o f risk assessment and management may be more or less formalized. Terminology In the context of risk management, several terms have a more precise meaning th an when they are used in everyday language. Hazard A hazard is a potential adverse effect of an agent or circumstance. For example, mes othelioma is a hazard of asbestos, and physical trauma from a fall is a hazard of working a t heights. A hazard may be serious (e.g. death) or relatively trivial (e.g. transient irrit ation of the upper airways). Risk Risk is the probability that a hazard will be realized, given the nature and extent of a person \200\231s exposure to an agent or circumstance. For example, the risk of mesothel ioma from asbestos depends on the type of \201 bre and the amount that it is inhaled. The re is no risk of mesothelioma from the handling of intact asbestos products if no \201 br es are inhaled. A risk in an individual corresponds to an excess rate of the adverse outcome in a populatio n of exposed people. Thus populations of asbestos workers have an elevated rate of mesothel ioma. Uncertainty Often there is uncertainty about the existence of a hazard (e.g. does radi- ofr equency radiation from mobile phones carry a hazard of brain can- cer), or about the levels of risk associated with exposures to a hazardous agent or circumstance (e.g. how much the risk of leukemia is increased by low levels of exposure to benzene). In managing risks, it is important to take account of uncertainties in the assessment of hazards and associ- ated risks. 21_Smedley_Chap21.indd 416 1/2/2013 12:33:17 PM CONCEPTUAL MODEL 417 Conceptual model A number of similar models are used in OH practice to summarize and guide the process of assessing and managing risks in the workplace and the environment. One examp le is given in Fig. 21.1. n o i t p e c r e p n o i t a c n u m m o c e c n a l l i k s i R h t l a e H k s i R i e v r u s t n e m e g a n a m k s i R : h t l a e H k s i R . g n h s i l l a n o i t a p u c c O i b u P t n e m e g a n a m d n a y c n e g r e m E n o i t n e v e r P s c m o n o c E l o r t n o c & g n n n a l p i l l i e w k c a l B , l a p m a R t n e m e g a n a M y t e f a S d n a h t l a e H f o n o i s s i w e v e R d n a . G K d n a t n e m i . n o i t a z i r e t c a r a h c t n e m m r e p e v i t a t i t n a u Q s s e s s a s s e s s a a r h d a S k s i R t i d u A y B k s i r . ) 9 9 9 1 ( k s i r . h t l a e h S . t n e m e g a n a m y t e f a s t h g i r y p o C t n e m l a n o i t a p u c c O t n e m g n e r u s o p x E e r u s o p x E s s e s s a i l l e d o m s s e s s a . t n e m e g a n a M d n a k s i R d n a l a c g o o m e d p E h t l a e H l a c g o o c x o T n o i t a c i f i t n e d t n e m t n e m i l a c n i d r a z a H l i l t n e m s s e s s a s s e s s a i i l c & 1 1 2 . i s s e s s a i i . g i F 21_Smedley_Chap21.indd 417 1/2/2013 12:33:17 PM CHAPTER 21 Risk assessment and risk management 418 General principles Risk assessment Assessing the risks and bene \201 ts from a possible co urse of action requires evaluation of relevant scienti \201 c evidence. There are four mai n elements to this. Typically, these elements are described in relation to potential advers e effects, but bene \201 cial effects can be considered analogously. \200 Hazard identi \201 cation: what are the potential adverse effects of the agent or circumstance? Hazard characterization: how does the probability of these hazards vary according to the nature and extent of exposure? Exposure assessment: what are the nature and extent of the exposures that will occur if the course of action is followed? Estimation of risk: what is the likely probability of each hazard if the course of action i s followed? For each risk estimate there should be an evaluation of the associated scienti \201 c uncertainty (might the true risk be much larger or smaller than the \201 gure est imated, and if so, how likely is this?). Risk management Risk management entails the application of value judgements to decide betwe en possible courses of action, given the estimated risks and bene \201 ts associated with each option. Value judgements should re \202 ect the inter- ests of all people who could b e materially affected by the decision, with greatest weight being given to the interests of those who will be most affected. Who makes the decision will depend on the number of people affected. If the important risks and bene \201 ts involve only one person, then ideally that individual should decide whic h option to follow. If more than one person will be affected and their interests con \202 ict, then the decision may require societal input (e.g. through an elected government or th e judiciary). For example, governments set exposure limits on hazardous substances in the w orkplace, taking into account the interests of both workers and employers. Frameworks for the assessment and management of risks Where complex, but similar risk manag ement decisions must be made on a regular basis (e.g. in the regulation of toxic chemicals in the workplace), a generic framework may be established within which risks are assessed a nd managed. This has the advantage of transparency (it is easier for affected parties to un derstand the basis on which decisions are made) and pro- motes internal consistency of deci sions. For example, the framework for regulation of pesticides in the EU speci \201 es sta ndard requirements for sci- enti \201 c data and the approaches that should be used to det ermine whether potential risks will be acceptable. 21_Smedley_Chap21.indd 418 1/2/2013 12:33:17 PM GENERAL PRINCIPLES 419 The precautionary principle As de \201 ned in 1992, the precautionary principle stated tha t \200\230where there are threats of serious or irreversible damage, lack of full scienti \201 c cer- tainty shall not be used as a reason for postponing cost-effective meas- ures to prevent environmental degradation \200\231. It has since been extended to encompass haza rds to health as well as to the environment. Essentially, it is an af \201 rmation that de cisions in risk management should take appropri- ate account of scienti \201 c uncertainty . 21_Smedley_Chap21.indd 419 1/2/2013 12:33:17 PM CHAPTER 21 Risk assessment and risk management 420 Sources of scienti \201 c evidence and uncertainty Sources of scienti \201 c evidence on hazard and risk Information about hazard and risk may come from various sources: \200 Ext rapolation from accepted scienti \201 c theory: for example, in assessing the health risks from static magnetic \201 elds, account is taken of the relevant principles of biophysic s Experiments in vitro : e.g. tests for mutagenicity in bacteria \200 Toxicological experim ents in live animals: these can be more informative, but are relatively expensive and must be justi \201 able in relation to the impact on animal welfare Studies investigating risk in humans: these may be experimental (e.g. randomized controlled trials (RCTs)) or observational (e.g. cohort and case-control studies). They have the adva ntage of avoiding the uncertainties of extrapolation between species, but are limited by th e practical and ethical constraints on research in humans. Moreover, they can only be condu cted after human exposure to a potentially hazardous agent has occurred Studies to assess patterns of exposure that may result from a risk management decision: depending on the nature of the exposure, these may use methods of occu pational hygiene, ergonomics, microbiology, psychology, or other scienti \201 c discipline s. Reasons for scienti \201 c uncertainty Scienti \201 c uncertainty in the assessment of ri sks may occur for various reasons. \200 Doubts about the validity of accepted scienti \201 c theory and of its extrapolation to the exposure of interest Possible differences in susceptibility to a hazard between humans and the animal species in which toxicology has been investigated, sometimes taken into account by application of an \200\230assessment factor \200\231 ( \200\230safety factor \200\231) Possible differences between individuals in susceptibility to a hazard (e.g. because of differences in genetic constitution, sex, age, coincident disease, and med ication, or aspects of lifestyle and environment). Again, an assessment factor may be used to allow for this De \201 ciencies in the design or execution of studies \200 Statistical uncertainties wh en results are based on \201 nite samples of observations that may be unrepresentative by chance. Con \201 dence intervals can be used to help gauge the potential for error of thi s type. 21_Smedley_Chap21.indd 420 1/2/2013 12:33:17 PM RISK COMMUNICATION AND PERCEPTION 421 Risk communication and perception Risk communication Good communication of risk is importan t for two main reasons: \200 People who take decisions in risk management ( \200\230risk managers \200\231) need to understand the likely risks and bene \201 ts of each possible c ourse of action. This information must be conveyed to them by the scientists who have asses sed the risks and bene \201 ts Where decisions in risk management are made at a societal level, the people affected need t o understand the basis on which decisions are made, and to have an opportunity for informed contribution to the decision-making (e.g. through consultation processes or lobbying of po liticians).