Transparency data

16th IIAC public meeting: Leeds, 11 July 2019

Updated 3 November 2023

Foreword

The sixteenth public meeting of the Industrial Injuries Advisory Council (IIAC) was held in Leeds on 11th July 2019. Since April 2018 there have been changes in the composition of the Council due to several members reaching the end of their terms of office. This has included a new Chair, Dr Lesley Rushton, who replace Professor Keith Palmer. I would like to thank Professor Palmer for all his help in ensuring a smooth transition and, of course, for all the major work he carried out for the Council and the important decisions reached during his Chairmanship. In addition to a new Chair, several new members have joined the Council with expertise including respiratory disease, musculoskeletal problems, epidemiology and occupational exposure assessment.

The public meeting held in July 2019 allowed interested members of the public to meet the new Chair and Council members, to hear presentations from them and to discuss directly some of the varied topics that the Council has been addressing. This year, as in previous years, the wide-ranging discussions raised some important issues and provided helpful and interesting views on the topics presented. Additionally, new and relevant concerns were raised, which the Council and the Department for Work and Pensions (DWP) will consider going forward. I would like to thank everyone who attended the meeting for contributing to a useful and productive occasion.

Dr Lesley Rushton
IIAC Chair

IIAC is a non-departmental public body which advises the Secretary of State for the Department for Work and Pensions (DWP) and the Department for Social Development (DSD) in Northern Ireland on the Industrial Injuries Scheme. The DWP and DSD are responsible for the policy and administration of the Scheme. IIAC is independent of the DWP and the DSD. It is supported by a Secretariat provided by the DWP and endeavours to work co-operatively with Departmental officials in provision of its advice.

This document is a record of the Leeds public meeting and covers events and discussions up to 11 July 2019. However, this report should not be taken as guidance on current legislation, nor current policy within the DWP nor DSD, as members may have expressed personal views, which have been recorded here for information.

Agenda

09:15 – 10:00 – Registration with tea / coffee

10:00 – 10:35 – Welcome remarks and setting the scene for the day – Chair of IIAC, Dr Lesley Rushton

How IIAC evaluates evidence on health risks associated with occupational exposure Chair of IIAC, Dr Lesley Rushton

10:35 – 10:45 – Q and A

10:45 – 11:30 – HAVS: objective testing for vascular disease – with Q and A – Dr Ian Lawson

11:30 – 11:45 – Tea / coffee break

11:45 – 12:30 – COPD: extending prescription to non-mining occupations and exposures – with Q and A – Dr Chris Stenton, Keith Corkan & Prof John Cherrie

12:30 – 13:30 – Lunch

13:30 – 14:20 – Overview of IIACs other work, including osteoarthritis of the knee - with Q and A – Prof Neil Pearce & Dr Valentina Gallo

14:30 – 15:15 – Open Forum and closing remarks – Hugh Robertson

15:15 – End of public meeting

Welcoming remarks and how IIAC evaluates evidence on health risks associated with occupational exposure

Dr Lesley Rushton, Chair of IIAC

1. Dr Rushton welcomed everyone to the Leeds public meeting and the IIAC members introduced themselves.

2. The Industrial Injuries Scheme provides non-contributory, no-fault compensation, which principally includes Industrial Injuries Disablement Benefit (IIDB). This is paid to people who become ill as a consequence of a workplace accident or an occupational or ‘prescribed’ disease.

3. The Scheme compensates employed earners; the self-employed are ineligible to claim IIDB for work-related ill-health or injury.

4. Certain prescribed diseases are given the benefit of ‘presumption’ – if a claimant is diagnosed with a disease and had an appropriate exposure then it is presumed that their occupation has caused the disease; the rule is complicated and two reports detailing the Council’s reviews of presumption have recently been published.

5. The Scheme compensates for “loss of faculty” and its resultant “disablement”. Disablement is decided by comparison to the condition of an age- and gender-matched healthy person and assessed by medical advisers engaged by the Department. Assessments of disablement are based on loss of function, rather than loss of earnings and are expressed as a percentage.

6. Thresholds for payment are applied such that, in general, payments can be made if disablement is equal to, or greater than, 14%. The exceptions to this are pneumoconiosis and byssinosis where payment can be made if disablement is 1% or more and occupational deafness where the threshold for payment is 20% disablement. Assessments of disablement can be aggregated (this is the process whereby two or more concurrent assessments are added together to produce one award of benefit).

7. Claimants can receive benefit from ninety days after the accident or onset of the prescribed disease; shorter periods of disablement are not compensated. IIDB can be paid 15 weeks following an industrial accident and prescribed diseases cannot be paid more than 3 months before date of claim.

8. IIAC is a statutory body, established under the National Insurance (Industrial Injuries) Act 1946, to provide independent scientific advice to the Secretary of State for the Department for Work and Pensions (DWP) and the Department for Social Development (DSD) in Northern Ireland on matters relating to the IIDB Scheme or its administration.

9. The members of IIAC are appointed by the Secretary of State after open competition, and consist of a Chair, scientific and legal experts, and an equal number of representatives of employers and employees. Officials from the Health and Safety Executive (HSE) and relevant policy divisions of the DWP, Ministry of Defence and DSD may attend IIAC meetings to provide information and advice. There are four meetings of the full Council per year.

10. The majority of IIAC’s time is spent providing advice to the Secretary of State on the prescription of occupational diseases. IIAC’s other roles are to advise on proposals to amend regulations under the Scheme, to advise on matters referred to it by the Secretary of State, and to advise on general questions relating to the IIDB Scheme. The Council has no involvement in decision-making of individual claims.

11. A permanent sub-committee of the Council, the Research Working Group (RWG), monitors and reviews medical and scientific literature to identify developments in the field of occupational ill-health which are then brought before the Council. This work is supported by a Scientific Adviser. The RWG meets four times a year.

12. IIAC also investigates diseases following referrals from the Secretary of State, correspondence from MPs, medical specialists, trade unions, and others, including topics brought to its attention by its own members and by other stakeholders. Public meetings are an important forum to draw attention to topics for the Council to investigate.

13. Industrial diseases (prescribed diseases (PD)) are grouped according to their cause, namely the name of the disease or the type of exposure/typical jobs.

Classification	Type	No. diseases
A	Physical cause	14
B	Biological cause	15
C	Chemical cause	34
D	Any other cause	13

14. IIAC uses a number of criteria in assessing the evidence needed to prescribe a disease, including:

• Scientific evidence
  – consistent independent good quality epidemiological evidence that the risk in workers in a certain occupation is much greater than risk to the general population
  – a clearly defined substance of concern, exposure and/or job/occupation
  – if available, evidence of a dose-response relationship between the exposure or occupation and increased disease risk
  – a clearly definition of both the disease of concern and how to diagnose it
• practical considerations that the prescription
  – can be administered effectively by decision makers without epidemiological experience
  – both disease and exposures are verifiable within scheme
  – the disease is a cause of genuine impairment/disablement

15. Deciding which diseases to recommend for prescription depends upon the complexity of the topic. “Straightforward” diseases include those that only occur due to particular work or are almost always associated or linked with work. Less “clear-cut” diseases require more extensive scrutiny. These could be common in the wider population due to non-work related causes and in individual cases there may have no reliable way to test if it is occupational or not. In order to be reasonably certain that work causes the disease IIAC looks for evidence that the disease is likely due to work on the balance of probabilities (‘more likely than not’) i.e. that the risk of the disease in a particular job or exposure to a hazard is more than double the risk than those not exposed.

16. Openness and transparency are essential criteria of IIAC and the Council ensures it meets these criteria through stakeholder engagement, and through a range of publications including command and position papers, information notes, annual reports, proceedings from public meetings and the minutes from full Council and RWG meetings.

17. The current and recent work programme for the period 2017-19 includes:

• diseases/injuries with multiple known causes
• coal mining, silicosis and lung cancer
• occupational exposure to silica and connective tissue diseases
• malignant melanoma in pilots and air cabin crew
• osteoarthritis in footballers
• non-malignant respiratory disease in coke oven workers
• hand Arm Vibration Syndrome (HAVS)
• review of use of formal tests for the vascular component in HAVS
• clarification of the guidance for assessors regarding interpretation of medical histories
• guidelines on reviewing and reporting of epidemiological studies

Comments, questions and answers from the ‘Welcoming Remarks’ and ‘How IIAC evaluates evidence on health risks associated with occupational exposure’ sessions

18. No comments and no questions asked.

Presentations

HAVS: objective testing for vascular disease

Dr Ian Lawson

1. Dr Lawson explained that this topic had arisen as a result of a question at the last public meeting relating to the wording of the prescription. The concern related to claims for sensorineural-only hand-arm vibration syndrome (HAVS); the term ‘continuous’ numbness or tingling had been used in the legislation whereas the Command paper used the term ‘persistent’ numbness or tingling. Dr Lawson gave an overview of HAVS and how it relates to IIDB PD A11. How vibration related disorders are prescribed and their prescription history was also described.

2. Several photographs were presented which illustrated how the conditions present themselves. Dr Lawson also defined the latent interval, i.e. the time between exposure and the onset of finger blanching.

3. There are two components of HAVS that can occur usually commencing in one or more fingertips:

• vascular as shown by episodes of intense blanching (whitening) of the skin induced by cold conditions that may go on to occur throughout the year
• sensorineural which can cause intermittent or continuous numbness or tingling, reduced sensory perception and dexterity

4. He explained that an audit of 100 consecutive claims for PD A11 showed no detriment to claimants as a result of the wording of the prescription. However, it became apparent that a number of vascular claims were being rejected because of the time-course of the disease. The Council decided to look into this and establish if any objective tests could be introduced into the assessment process to assist with this issue (sensorineural testing is already used in some IIDB assessments).

5. A summary of pathophysiology of HAVS was given to illustrate the complexity of the condition and how objective tests might be applicable.

6. The available tests which might be applicable to HAVS were described and included:

• Cold Water Provocation Test, CWPT
• Finger Systolic Blood Pressure, FSBP
• Capillaroscopy
• 8MHz Doppler – demonstrated during the talk

7. The classification system for the severity of the disease was discussed.

8. Having researched the tests available, it was concluded:

• symptoms can progress rapidly say 6 months with very high exposures
• symptoms may plateau despite ongoing exposure with minimal progression of stages even with long term exposure
• symptoms may occur for the first time up to 12 months after cessation of exposure

9. IIAC has published a position paper, available in candidates’ packs, which set out the views of the Council:

• Objective testing was not recommended but would be kept under review; The available tests at the time were:

  – too unwieldy and complex to be used in an assessment setting
  – require specialist training
  – not sufficiently reproducible
  – history taking – the Council suggested that guidance for medical assessors should be amended to allow for time-course of the disease
  – digital photography – the Council recommended that claimants should be encouraged to provide digital photographs in support of their claim but that these should not be mandatory

Comments, questions and answers from the ‘HAVS: objective testing for vascular disease’ session

10. Dr Rushton commented that it is difficult for the Council to monitor easily whether or not the intent of the Council in its wording of prescriptions or legislation or advice is working in reality. Statistics are available but are limited in their scope. Dr Rushton explained that the audit mentioned earlier in the talk was burdensome for both the IIAC members who reviewed the clerical files, but also the DWP staff who had to prepare these. Dr Rushton reiterated how important public meetings were to the Council and how it relies on stakeholders to alert it to issues.

11. A representative from the NUM, Robert Fitzpatrick, asked if a claimant is diagnosed with Raynaud’s, does this discount their claim for white finger or can they have both?

12. Dr Lawson thought that this depended upon the onset of symptoms, so if they had Raynaud’s diagnosed before they started using vibrating tools or there was a strong possibility the condition wasn’t caused by work, e.g. family history, then this may not be allowed. However, if this is not the case then presumption applies that both the conditions are caused by work and would be presumed as prescribed diseases.

13. A Miner’s Lodge representative raised a query concerning where a claimant has been diagnosed with PD A11 and carpal tunnel syndrome, and sometimes an offset has been applied. This has been queried by a vascular surgeon as 2 different conditions with different symptoms.

14. Dr Lawson advised these would be classed as co-morbid conditions i.e. one can have sensory HAVS as well as carpal tunnel syndrome – so there should be no reason why an individual should not have an aggregated claim i.e. have both together. This would need to be taken back to DWP to answer.

15. Dr Rushton commented it is possible to have separate claims for the same exposure and that these would be aggregated.

16. Terry Woolmer from Engineering Contractors Assoc. asked how easy or difficult it was to attribute muscular weakness to work?

17. Dr Lawson said this is very difficult. In previous studies on grip strength in miners, relatively young men were presenting with this phenomenon but there was no explanation, no pathophysiology, why this was the case. It would be very difficult to prescribe for something like that.

18. Chris Skidmore, NUM, submitted a written question in advance, which referred to a freedom of information request which asked the DWP for statistics for PD A11 claims 2017/2018.

• 1110 new claims
• 200 claims resulted in award of disability
• 890 claims disallowed
• 20 claims withdrawn

19. Mr Skidmore was concerned about whether the stringency of the IIAC advice for prescription was too high or whether the DWP was not interpreting this advice correctly.

20. Mr Skidmore also raised an issue that he felt was an example of IIAC’s advice being ignored, where the Centre for Health and Disability Assessments (CHDA) had responded to an enquiry about a rejected claim that there was ‘no equipment available’ i.e. a situation where a medical practitioners had to travel to see a claimant and had not taken appropriate equipment with them. Mr Skidmore felt that this could result in no award for disability. He cited a specific case where a claimant was too ill to travel, and a medical practitioner turned up with no equipment – photography on this occasion was of little use in this instance as it was copied onto low grade paper. The claimant was turned down, even by a Tribunal, despite clearly having the condition. Mr Skidmore asked what could be done?

21. Dr Lawson stated it was difficult to comment on individual cases, but hoped that the preceding presentation had answered many of the questions relating to HAVS – the Council had listened to the concerns and had strived to address them. The recently published position paper recommends the assessors guidance be relaxed which can translate into better guidance. Dr Lawson agreed with the concern around testing equipment as it is easily portable and should be available. For sensory only HAVS, generally more stringent tests, under controlled conditions, are commissioned, otherwise standard tests are applicable.

22. Dr Rushton stated IIAC are unable to alter an outcome for individuals but the concerns would be minuted and published as a matter of public record. She re-iterated the importance of being able to monitor the outcomes of claims and that the Council may have picked up on the HAVS issue earlier if data had been readily available. However, currently this is difficult due to the clerical nature of the claims process. Computerisation would help with this.

23. Another delegate commented that when CHDA make an assessment they make a record on their own computer system, of what the outcome is – why can’t this be made available instead of having to provide a clerical file? Dr Rushton thought this would be a good idea and would discuss with the relevant officials. Being able to monitor how claims are progressing is important, especially with Dupuytren’s contracture regulations coming into force in due course.

Chronic obstructive pulmonary disease (COPD): extending prescription to non-mining occupations and exposures

Dr Chris Stenton, Keith Corkan and Prof John Cherrie

24. Dr Rushton started the next topic by introducing the speakers and stating she had an interest in looking how prescriptions such as COPD could be extended to other occupations where epidemiological evidence of a doubling of risk may be lacking but where parallels could be drawn from occupations with similar exposures

25. The presentation commenced with an overview by Keith Corkan of legal proceedings published in the media which alerted the Council to the issue in coke oven workers.

26. A history of class action litigation relating to COPD (or ‘chronic bronchitis and emphysema’, as it was formerly known as) described successful claims against the British Coal Corporation, who were found to have failed to take reasonable steps to combat the effects of coal dust and that injury was caused on a balance of probabilities.

27. Under these circumstances, the ‘doubling of risk’ for legal purposes is not always appropriate, for example the Bonnington test (common law negligence) would apply where 2 agents have cumulatively and simultaneously caused the disease. The 2 tests are similar and equate to balance of probabilities.

28. Later legal cases involving phurnacite workers found liability for some respiratory diseases which was a breach of statutory duty and under the Bonnington test.

29. Coke oven workers were represented when a successful claim for damages for chronic bronchitis was brought by the estate of a deceased worker. Causation and breach of duty were admitted.

30. The presentation went on to describe the prevalence of COPD and its association with occupational exposures in a general population (Dr Chris Stenton).

31. The chances of a diagnosis of COPD are related to:

Diagnosis related to	Percentage
Age	3% more per year
Sex	60% more if female
Wealth	50% more in rented housing
Smoking	1% more for every year of smoking
Occupational exposures: - mining - welding - factory work - asbestos - any dusty work	35% more if exposed

32. An overview of COPD was given. COPD is characterised by airflow obstruction (airway narrowing) and emphysema. It was previously often referred to as chronic bronchitis and emphysema but the term bronchitis is now used to describe a productive cough alone. COPD is a common condition with about 1.2 million affected individuals in the UK. It is diagnosed using spirometry to measure lung function including the volume of air expelled in the first second (FEV1) and the total volume of air expelled (FVC). The main cause of COPD is smoking but it is also associated with genetic factors, smoke from open fire cooking, urban life, long-term dust and other occupational exposures.

33. It was stressed that COPD caused by work looks the same as COPD from other causes and finding a cause relies on population studies. However:

• people at work have better than average lung function (healthy worker effect)
• those most affected leave work (survivor effect)
• there are few records of past exposure
• there are effects of age, gender and smoking

34. A slide from the Health & Safety Executive (HSE) was presented which listed several jobs and substances which have been linked to possible increased risks for COPD, for example coal mining, working in agriculture, construction, pottery/ceramic, quarries and stonemasons, textiles, exposure to dusts such as grain and flour, silica, welding fumes and minerals.

35. COPD has been widely studied in the coal mining industry and a history of these studies was described. Currently, COPD is only prescribed for coal workers and a history of this prescription was described. In the past IIAC have also investigated COPD and several other exposures but with the exception of cadmium exposed workers, these did not meet the criteria for prescription.

36. Further population studies were described where COPD has been demonstrated to have an effect due to occupation:

• the US NHANES study
• the UK Biobank study

37. The presentation continued with a description of coke oven work, the process and the machinery involved. There are different job roles within a coke plant and workers may be exposed to several different substances/mixtures, including fumes, coal and coke dust, toxic gases and vapours.

38. Lung cancer is a recognised risk of coke oven work and has been a prescribed disease since 2011. Benzene-soluble particles are believed to be the cause of the cancer and levels have been monitored in coke plants. Coal dust is prevalent in coking plants, but little information is available on the actual exposure levels.

39. Dr Stenton has reviewed the literature on coke oven works and COPD. There are a number of mortality studies but these are not very useful in assessing the issue of COPD as many of those with this condition will not die from COPD, but often from some other cause.

40. There are a small number of studies which have investigated lung function in coke oven workers and an overview of these was presented. Some of these studies had their merits, but most had drawbacks. Most show a link between reduced lung function and work in coke ovens. A Chinese study showed the clearest evidence for occupational COPD in coking plants.

41. The challenge of how to interpret the scientific evidence from these lung function studies and relate them to the requirements of the industrial injuries scheme for prescription was discussed briefly by the speaker. IIAC will continue to consider this issue for coke oven workers and also to investigate whether and how prescription for COPD could potentially be extended to other occupational circumstances.

Comments, questions and answers from the ‘COPD: extending prescription to non-mining occupations and exposures’ session

42. Dr Rushton thanked the speakers and commented this is an ongoing piece of work and has wider connotations.

43. A delegate from the Durham Miners Association asked about the 20-year rule in the COPD prescription and stated there were 2 recent tribunal cases where both claimants had evidence from chest consultants to confirm their COPD had been caused by exposure underground. The tribunal were sympathetic, but stated they had to abide by the 20-year rule. The delegate stated that when there was medical evidence, these claimants should have been allowed their claim.

44. Dr Rushton replied that a claimant’s medical evidence would be given to confirm the disease but would not relate to the qualification for the prescription. The 1996 IIAC paper where the evidence relating to the prescription is described in detail, comments on the 20-year qualification. The paper acknowledges that some mines were dustier than others, so that COPD might occur in some workers who didn’t reach the 20-year threshold. However, this is countered by those who worked in less dusty mines but still qualified for IIDB after 20 years. The paper also comments that it would be impractical to require a claimant to provide proof of the number of hours worked and what their exposure was. This would be very difficult for claimants and for those administering the scheme.

45. Another delegate from the National Union of Mineworkers (NUM) stated there was some agreement with Dr Rushton’s response, but added the prescription was written many years ago. Modern mining practices using automated machinery generated much more dust. A comparison was drawn between other occupations, such as cleaners who work in air conditioned buildings and miners who work in very confined spaces. The 20-year rule should be looked at again.

46. It was stated the Council are not actively considering other occupations but just gave an example of where risks were increased. Much more reactive chemicals are used in some occupations which may be potent causes of COPD.

47. Another delegate from the NUM raised the point of the 20-year rule which is thought to be outdated. After the strike, miners were expected to work longer hours with much bigger machinery to produce much bigger yardages. So exposure was higher over shorter time.

48. This delegate also said that when miners try to claim for pneumoconiosis, they are given a diagnosis of COPD which is carte blanche and prevents claims under the 1974/1979 Workers Compensation acts. The DWP appears to be hiding behind the COPD diagnosis which covers a lot of other diseases.

49. Dr Rushton stated she was unable to answer that, and would have to pass that to the DWP. If general points are being brought up, then that is useful and important and the Council can go back to the DWP with that information.

Overview of IIACs other work, including osteoarthritis of the knee

Prof Neil Pearce
Dr Valentina Gallo
Prof Neil Pearce

50. The presentation commenced with an overview of diseases with multiple causes. A disease may be prescribed if there is a recognised risk to workers in an occupation, and the link between disease and occupation can be established or reasonably presumed in individual cases.

51. For some diseases attribution to occupation flows from specific clinical features of the individual case. For example, the proof that an individual’s asthma is caused by their occupation may lie in its improvement when they are on holiday and regression when they return to work. Also in the demonstration that they are allergic to a specific substance which they encounter only at work.

52. It can be that a particular disease only occurs as a result of an occupational hazard (e.g. coal workers’ pneumoconiosis) or that cases of it rarely occur outside the occupational context (e.g. mesothelioma), or that the link between exposure and illness is fairly abrupt and clear-cut (e.g. several of the chemical poisonings and infections covered by the Scheme).

53. Increasingly, however, prescription has proved possible for diseases that are not only caused by occupation but common in the population at large, and which, when caused by occupation, are clinically indistinguishable from the same disease occurring in someone who has not been exposed to a hazard at work.

54. Examples include lung cancer, chronic obstructive pulmonary disease and osteoarthritis of the knee. Other factors at play in the population (e.g. smoking, recreational knee injury) account for a proportion of such cases and no clinical features in the claimant allow reliable attribution to employment.

55. Prescription for such diseases involves identifying – using epidemiological research evidence – the work circumstances in which the average risk of disease is increased by a factor of two or more. The requirement for at least a doubling of risk follows from the fact that if a hazardous exposure doubles risk, for every 50 cases that would normally occur in an unexposed population, an additional 50 would be expected if the population were exposed to the hazard. If the risk of the disease is doubled or greater it is thus likely to be due to work on the balance of probabilities i.e. ‘more likely than not’.

56. Some key issues were highlighted:

• most diseases have multiple cause - just because someone was exposed to one important cause (e.g. smoking) it doesn’t mean that other causes (e.g. asbestos) did not also play a role and contribute to a substantial proportion of cases
• even if one factor (e.g. smoking) has a high relative risk, another factor (e.g. asbestos) with a lower relative risk may also play a role and contribute to a substantial proportion of cases
• the percentage of cases caused by different factors can add up to more than 100% if some cases are caused by combinations of factors

57. Multiple causes of a disease are discussed in detail in a Command paper published in 2018 ‘Diseases with multiple known causes, occupational injuries and medical assessment’; the issue of non-occupational causes of diseases before or during employment is specifically addressed in the paper.

58. Everyone has many risk factors such as genetic predisposition, exposures outside of work, etc. The effects of these ‘other’ exposures are usually difficult to predict, but are often weak. However, some tribunal rulings have led to medical assessors having to predict the future course of disablement, e.g. if the claimant has had previous surgery on an organ or joint currently causing disability.

59. The command paper considered 2 different circumstances:

• when a disease or injury moves someone from apparent normality to disability as an ‘all or nothing’ (stochastic) event (e.g. development of a cancer or an accidental injury)
• when there is a gradual development of functional impairment (e.g. the development of osteoarthritis in the knee)

60. In the first situation, if the evidence that disease or injury is attributable to work on the balance of probabilities, irrespective of other non-occupational causes, then all of the disablement arising from the disease is attributable to work on the balance of probabilities and no deduction for a non-occupational cause should be made.

61. For example:

Worker A: smoked and also worked with asbestos and developed lung cancer. No deduction should be made for smoking as smoking does not affect the decision on causation (by asbestos).

62. However, in the second situation where there is gradual development of a functional impairment, deductions are sometimes made for ‘other effective causes’; these deductions are rare, but their impact on individual claimants may be significant.

63. For example:

Worker B: played in a rock band but had good hearing when starting employment in the relevant industry; subsequently developed further hearing loss as a result of work in the industry.

• a deduction should NOT be made for the non-occupational risk factor (playing in a rock band)

Worker C: played in a rock band and experienced some hearing loss BEFORE starting employment in the relevant industry; subsequently developed further hearing loss as a result of work in the industry.

• a deduction should be made for the pre-existing hearing loss.

Worker D: good hearing before starting employment in the relevant industry; developed hearing loss as a result of work in the industry AND playing in a rock band (during the same period). In theory, some deduction could be made on the basis of the percentage of the hearing loss which was due to the non-occupational risk factor. In practice, this is usually impossible to do.

• only recommend considering the occupational exposure, and not making deductions for the non-occupational exposure

64. In the situation where there is gradual development of a functional impairment the Council therefore recommended that deductions are not made for non-occupational risk factors when these factors have not resulted in an ascertainable disablement, prior to the start of the employment. This advice was provided to support medical assessors and the Council felt that regulatory change was not required.

65. The presentation then went on describe other IIAC work which has taken a considerable amount of the Council’s time:

• osteoarthritis of the knee in footballers
• melanoma in aircrew

66. Osteoarthritis of the knee in footballers:

Organisations representing footballers have approached the Council citing evidence that former footballers have increased risk of osteoarthritis (OA) of the knee.

• a recent UK cross-sectional study found that OA of the knee is two to three times higher in male ex-footballers
• several other studies have been published from other countries

67. The papers were evaluated and upon initial investigation it would appear:

• there is a clear greater than two-fold risk, but this is mainly in footballers who had a knee injury
• the risk appears to be less than two-fold in footballers who did not have a knee injury during their career

68. However, this is a complex issue and requires more time to extract and fully analyse the data in the publications. The Council is continuing with its investigation and council members with musculoskeletal expertise will give their expert opinion in the near future.

Comments, questions and answers from the first part of this session on osteoarthritis of the knee in footballers

69. A delegate commented that osteoarthritis of the knee was becoming more prevalent with players starting at a young age – would this have an impact in the future?

The answer is unknown, but seems plausible as the sport is now much more intense.

70. A delegate asked how long would a player need to have played football to qualify for benefit if this becomes a prescribed disease, compared with that required for miners?

71. This is still something the council is looking at, so was unable to comment on that at this time or put a figure on it, but the average length of a footballing career is approximately 15 years.

72. A delegate asked if a footballer made a claim for an industrial accident following knee injury, would they then be able to claim for an industrial disease if they develop osteoarthritis?

73. There have been no decisions made yet on the recommendation, but that is a possible recommendation.

74. A delegate asked about the types of environment and certain occupations which would not qualify.

75. The differences between this and the evidence in miners is that the increased risk of osteoarthritis occurs whether or not a knee injury has occurred. The council are looking carefully at the risk to footballers who have not had a knee injury.

76. A delegate asked about whether the condition was different for footballers who played in different positions e.g. goalkeepers.

77. If you were considering the impact of heading a ball then yes, this could well be an issue but not when looking at knees.

78. A delegate made the point that most footballers were self-employed, so would not qualify if this were prescribed.

79. This was agreed, but stated that employment status was not considered when evaluating the science. A point was made that many players in the lower leagues were employed.

80. The above point led onto another point that self-employed farmers who develop osteoarthritis of the hip are unable to claim; however, there are also farm workers who are employed.

81. A delegate asked if this was likely to arise in other sports?

82. This is certainly possible – the topic arose because of correspondence from representatives of footballers, so the Council is just focussing on footballers at the present time.

83. Another delegate picked up on this and remarked that rugby union players could be affected and asked if playing even if a knee injury had occurred was another factor in terms of causing more damage?

84. This is unknown and probably not addressed in the available epidemiological studies – it would be difficult to define sub-groups in more detail other than those with/without previous knee injuries.

Overview of IIACs other work – Melanoma risk among pilots and cabin crew

Dr Valentina Gallo

85. Dr Rushton introduced the topic by explaining the council started to look at this following correspondence where skin cancer had developed following exposure as a seafarer. An initial review of the evidence of melanoma and occupation highlighted an excess risk in pilots and cabin crew. The Council has therefore been carrying out a detailed review of the evidence in these groups.

86. The presentation stated with a description of melanoma and its prevalence:

• melanoma is the fifth most common cancer in the UK
• around 15,000 new cases of melanoma are diagnosed each year
• more than a quarter of skin cancer cases are diagnosed in people under 50; the risk rises with age
• about 2,500 people die every year in the UK from melanoma
• the incidence of melanoma has increased greatly since the 1990s.

87. Melanoma arises in different anatomic sites in men and women:

• men = trunk
• women = legs (including thighs)

88. The well-established link between sunlight and melanoma was discussed:

• exposure to UV light (sunlight) increases the risk of melanoma
• intermittent and high intensity sunlight provides the strongest association with increased risk, in particular early in life
• less clear is the role of continuous exposure

89. The published evidence relevant to aircrew was introduced and described:

• 19 studies included
• 266,431 individuals
• standardised incidence ratio (SIR) for any flight-based occupation 2.21 (95% C.I 1.76-2.77)
• pilots and cabin crew have approximately twice the incidence of melanoma compared with the general population

90. Melanoma risk in pilots: based on 7 studies where melanoma was histologically confirmed, the SIR for melanoma in pilots was 2.03 (95% CI 1.71–2.40).

91. Melanoma risk in cabin crew: based on 3 studies the SIR for melanoma in cabin crew was 2.12 (95% CI 1.71–2.62).

92. It was found length of service was a factor:

• the risk of melanoma increased with increasing the number of flying hours in some studies
  – doubling only among those flying ≥5,500 hours at the time of the entry into a British study
  – doubling of risk among those flying 5,000+ hours in a Danish study
  – doubling of risk among those flying >10,000 hours in a Norwegian study

Overall this gave a SIR of 10.3 (1.7-197) in pilots with more than 10,000 flying hours:

• other studies did not find an association with length of service

93. The sites where melanoma develop was discussed:

• Nordic airline pilot study found similar increased (doubled) risk for melanoma in all areas: head & neck, trunk, limbs
• in another Scandinavian study the risk was increased in particular for the melanoma on the trunk

94. Possible mechanisms for causes was discussed:

• solar UV irradiation (including recreational exposure)
• cosmic radiation
• disruption of the circadian rhythm
• diagnostic bias

These potential causation mechanisms were discussed in more depth.

95.Solar UV radiation

• ultraviolet radiation (UV) A and B reach the earth surface and are potentially damaging
• cockpits are reasonably well protected from UVB radiation but recent studies have demonstrated that UVA can penetrate windshields at low levels. This is unlikely to contribute substantially to total UV exposure
• the Council have been investigating potential sources of UV exposure during occupation (for example during non-flight work and during stop over periods); recreational exposure has also been debated but there is little firm data on this

96. Cosmic radiation

• gamma and neutron radiation
• aircrew are exposed to roughly twice the average annual dose of ionising radiation than the general population average
• evidence on an association between cosmic radiation and melanoma in aircrew is inconsistent
• no evidence available on ionising radiation for medical use and melanoma in the general population
• biological plausibility is low

97. Disruption of the circadian rhythm

• there is no strong evidence of increased risk of melanoma in other shift-workers
• the majority of evidence on melanoma in aircrew comes from short-haul routes (minimal circadian rhythm disruption)

98. Diagnostic bias

• aircrew undergo regular medical check-ups and might be more likely to be diagnosed with melanoma compared to the general population
• it is unlikely to explain the findings as mortality from melanoma is increased as much as incidence

99. Conclusions

• there seems to be a doubled risk of melanoma among aircrew compared with the general population
• the mechanism underlying this association is not yet clear

Comments, questions and answers from the second part of this session – Melanoma risk among pilots and cabin crew.

100. Dr Rushton thanked the speaker and explained no conclusions had been reached by the Council – it was unusual as there is a clear doubling of risk but an explanation of the cause is as yet unclear.

101. A delegate from the Unite union asked if there had been any discussion on toxic cabin air and how this might have an impact?

102. It was explained toxic cabin syndrome had been looked at previously but the Council found no evidence of a doubling of risk; it is unlikely to impact on skin cancer risk but may cause respiratory or eye irritation. Other industries have unexplained excesses of melanoma, for example, in the oil industry. Pilots are 2nd on the list of deaths from melanoma in the UK.

103. A delegate asked if pilots were subject to certain levels of radiation exposure (20 mSv/year) and why were these limits set?

104. The radiation aircrew get is still lower than that for medical reasons in the general population. However, they are a group of radiation exposed workers who do not wear monitoring badges. The exposure is estimated on flying hours and based on modelling systems of cosmic radiation values at various altitudes. Cosmic radiation is unlikely to be the causal mechanism as this will affect deep into tissues and organs. The dose pilots receive is thought to be 2-6 mSv/year.

105.The point was made by a delegate that pilots are assessed for cosmic radiation exposure, but cabin crew are not – they are likely to be exposed in the same way.

106. A comment was made that frequent flyers accumulate a lot of flying hours, but this is unlikely to be anywhere near that of air crew.

Open forum and Closing remarks

Mr Hugh Robertson

107. Mr Robertson opened the floor to the attendees, inviting questions and comments on any aspect of IIAC’s work or the presentations delivered during the meeting.

108. NUM Yorkshire submitted written questions prior to the public meeting, some of which related to Departmental procedural issues, rather than decisions of the Council.

109. Some written questions, for example from the Derbyshire Asbestos Support Team, had been addressed within the margins of the meeting.

110. The NUM indicated a written question on HAVS had been mostly addressed by the earlier presentation. However, concern was raised that the work of the Council was being ignored by the people it is supposed to influence. It was understood individual cases cannot be discussed, but these individual cases accumulate to become 40-60 instances a year and it is the lack of consistency with the way they are dealt with is frustrating.

111. The NUM continued by giving examples of situations where workers with HAVS fail to get IIDB. Some workers develop HAVS through using vibrating tools but when they change jobs they find that they cannot do it because of their condition, so end up losing it. Their condition may not be sufficiently severe to attract IIDB due their classification/staging on the scales used (e.g. Stockholm). Other examples are when workers claim later in life when their dexterity has deteriorated, but are unsuccessful as they do not meet the qualifying criteria. As you get older, what you can achieve gets worse especially if you have a disability associated with HAVS on the threshold. Have any studies been done comparing age matched subjects who have never used vibrating tools and do not have the disease to those who have the disease? How do their dexterities compare?

112. A Council member stated that was a difficult question to answer, but they thought there were 2 different issues:

• the diagnosis and classification of the disease
• the disablement/functional effect

The qualifying criteria for HAVS was described as detailed in the prescription and it was explained that specialist tests would need to be performed to assess sensory-only HAVS.

The issue of function does not always relate to the scale – other functional assessment tests such as the pegboard test need to be carried out. These tests have age-related normative data with age bands up to 80+ so should accommodate someone claiming later in life.

113. A delegate from the Unite union referred back to the presentation delivered by Dr Rushton and asked what happens if IIAC makes a recommendation and the Secretary of State (SoS) doesn’t agree?

114. Dr Rushton stated that in the case of Dupuytren’s, Council members met with the Minister when their advice was turned down.

115. The delegate stated they would like to know what would happen in general and not in the specific case of Dupuytren’s.

116. It was stated IIAC just provides advice, SoS doesn’t have to accept this. DWP policy officials will advise on the potential scale of impact and cost. When SoS decides not to accept IIAC’s advice, they have to give their reasons for this and the Council have the opportunity to respond and correct any misunderstandings or misconceptions. However, if something is turned down on the basis of costs, the Council has little influence over that.

117. It was stated this has only happened once and that was for Dupuytren’s and this was overturned after members met with Minister. If irrational decisions based on cost were made, this would have to be justified to Parliament and in that instant pressure could be brought using stakeholders such as those present. It was pointed out by a Council member that cost is not an influencing factor when coming to a decision, which is objective and based on facts. Sometimes IIAC may give an indication of expected operational impacts such as numbers of potential claimants.

118. A delegate asked about a NUM question posed at the IIAC 2017 meeting where the level of disability for a litre drop in FEV1 was discussed. The answer given did not address the level of disability. There was so much inconsistency in levels of awards.

119. The Council was unable to answer questions which should be directed to the DWP, but it was stated the Council do not get detailed statistics on IIDB awards and welcomed knowing when issues occurred. If this was within the remit of the Council they could take it forward, e.g. something within the wording of a prescription or inadequate guidance.

120. Another delegate stated they found assessments varied according to the discretion of individual doctors.

121. It was stated if any hard evidence was available, the Council could ask the DWP to look at their processes for assessments.

122. Another delegate challenged the Council on the criteria set for the prescription of PD D12 – why can disability not be described for the 1 litre drop?

123. The Council responded by saying they do not decide the level of disability as this is set by DWP. Respiratory impairment is termed in the paper recommending prescription and stated the 1 litre drop would determine sufficient lung impairment to qualify, but it did not specify the degree of disablement.

124. A delegate who represented members who worked in the youngest of the mines asked if the 20-year rule for COPD (PD D12) could be re-examined as after the miners’ strike the industry had started to use more mechanised mining and longer shift patterns were introduced. Miners were exposed to dustier conditions over longer shifts. Some miners have been diagnosed with the 1 litre drop, but do not qualify as they had not met the 20-year time requirement. Some non-smokers had developed the condition after 14 years’ exposure.

125. The Council agreed it could look at this due to the changes in mining practices and determine if there were coal board exposure data to inform discussions.

126. A delegate from the GMB union raised the issue of emerging health risks/conditions:

• glyphosate and potential risk of non-Hodgkin lymphoma in horticultural and agricultural workers
• rubber crumb and recycling risk – prevalent in sports grounds and playgrounds, risks of developing cancers

127. An IIAC member commented on glyphosate as they had worked with IARC who originally looked at this. It was stated the IARC scientists who had evaluated the carcinogenic potential of glyphosate had come under severe attack from industry. Glyphosate was classified as category 2A – possible carcinogen. Most studies have shown a relative risk of 1.3-1.5, so not double the risk. It is not clear if this would qualify for prescription. The IARC monograph will be looked at by the Council.

128. The delegate cautioned about downplaying the health risks as some studies had been sponsored by industry to generate doubt.

129. The IIAC member commented they were well aware of the possible involvement of industry in trying to influence the thoughts on glyphosate and had concerns about industry representation in the media disputing the IARC findings. When a topic is looked at, the Council takes note of who has sponsored/funds the studies and proceeds with caution.

130. Dr Rushton commented that the IIAC work programme will have topics which need to be prioritised and some will be on a longer timescale. Some have to take priority such as Ministerial correspondence which require responses. Rubber crumb and glyphosate will be added to this list. If any evidence/information is available, the Council would be grateful to receive this.

131. A delegate representing miners stated there was anecdotal evidence in mortality cases which involved COPD that there was a link with chronic kidney disease. The Council was asked if this could be investigated.

132. An issue around claims for osteoarthritis of the knee in mineworkers and the types of underground jobs which would qualify for the prescription was dealt with in the margins of the meeting. The Council agreed there was a case and would take this forward with the DWP.

133. The speaker invited Dr Rushton to give a summary of the day and give an indication of the ongoing work of the Council.

• Dr Rushton stated some of the ongoing work presented at the meeting was difficult to evaluate e.g. melanoma in air crew
• another difficult, longer term, issue being dealt with is COPD in coke oven workers as there is not a clear way forward for prescription
• there are some more general issues which IIAC will consider in future such as reviewing some of the current prescriptions and considering whether they should be updated to reflect changes in exposure situations. For example, construction workers are not specifically mentioned in some prescriptions, such as silica or asbestos related prescriptions
• longer piece of work will be to look at how prescriptions can be extended to include other industries for COPD and other respiratory diseases. Silica/silicosis in particular is restricted and other industries are impacted such as tilers and work involving reconstructed stone
• this will include investigating methodologies to extend these prescriptions where doubling of risk is not apparent due to small number of studies available. Parallel exposures could be used in these instances
• some of this work is time consuming, so the Council may ask for funding for these issues to be investigated externally
• other work to look at, and brought up at the meeting, was glyphosate. Also another IARC monograph on welders will be considered e.g. ocular melanoma
• in addition, recently IARC have evaluated breast cancer, prostate cancer, colorectal cancer and other cancers in relation to night shift work; this will also be examined by IIAC

134. Dr Rushton finished by thanking everyone for coming and contributing to the public meeting. She thanked IIAC members including the speakers and the DWP staff for all their work in organising the meeting. Special thanks were given to Mr Hugh Robertson who has contributed significantly to the work of the Council and is stepping down.

List of delegates

Surname	First name	Organisation
Agius	Raymond	IIAC Member
Baxter	Kay	Sheffield Occupational Health Services, Occupational Health Specialist Practitioner
Bennett	Tracy	Sheffield Occupational Health Services, Clinical Nurse Manger
Benning	Faye	DWP
Bedford	Richard	Unite the Union, Yorkshire & Humber TUC Health & Safety Forum Convenor
Burton	Kim	IIAC Member
Cahill	Simon	NUM
Cherry	John	IIAC Member
Chetland	Ian	IIAC Secretariat
Claughan	Lawrence	Durham Miners’ Association, Executive Committee Member
Corkan	Keith	IIAC Member
Cummings	Alan	Durham Miners’ Association, Easington Miners Lodge Secretary
Duff	Matthew	Scottish Government
Fenn	Pauline	Sheffield Occupational Health Services, Occupational Health Specialist Practitioner
Fitzpatrick	Robert	NUM
Gallo	Valentina	IIAC Member
Hall	Mark	RMT, TU Coordinator
Hassell	Garry	RMT, Health & Safety Officer
Hawkins	Andrew	RMT, Network Rail Health & Safety Rep
Hegarty	Catherine	IIAC Secretariat
Holmes	Tony	Unite the Union, Safety Rep
Horsefield	Richard	Unite the Union, Senior Safety Rep
Jandu	Jatinder	Coventry City Council, Senior Welfare Rights Officer
Johnson	Alan	Durham Miners’ Association, Executive Committee Member
Kent	Maurice	NUM, Yorkshire Area, Welfare Benefit Officer
Khan	Sayeed	IIAC Member
Lawson	Ian	IIAC Member
Loftus	John	DWP
Lowman	Dave	NUM
Mardghum	Alan	Durham Miners’ Association, Secretary Executive Committee
Mitchell	Karen	IIAC Member
Musgrove	Stephen	Durham Miners’ Association, Executive Committee Member
Ogden Rita	Sheffield Occupational Health Services, Occupational Health Specialist Practitioner
Parkinson	Carl	NUM
Penny	Judith	DWP
Pearce	Neil	IIAC Member
Polson	Keith	NUM
Rayner	Jayne	HMCTS-SSCS Tribunals, Chief Medical Member
Revill	Paul	CMS Cameron McKenna Nabarro Olswang LLP, Lawyer
Rimmington	Michael	RMT, Health & Safety Rep
Robertson	Hugh	IIAC Member
Round	Diane	DWP
Rushton	Lesley	IIAC Chair
Russell	Doug	IIAC Member
Sharma	Vijay	DWP
Shears	Daniel	GMB, Health, Safety & Environment Director
Skidmore	Chris	NUM, Yorkshire Area Chair
Stenton	Chris	IIAC Member
Thompson	John	NUM
Tomlin	Helen	Thompsons Solicitors, Solicitor
White	Andrew	IIAC Member
Whitney	Stuart	IIAC Secretariat
Woodward	Natalie	Macmillan, Derbyshire Asbestos Support, Support Worker
Woolmer	Terry	Engineering Construction Industry Association