22 October 2020
From the start of the pandemic there has been a focus on the identification of individuals at greater risk of contracting or having an adverse outcome from SARS-CoV-2, and on measures to mitigate these risks in both community and work settings, which are often interlinked.
Initial classification by PHE, in March 2020, of two high-risk groups, the extremely vulnerable, and those at clinically increased risk of severe illness from COVID-19 was based on older age and pre-existing health conditions, both already identified as significant risk factors for the influenza virus.
With increased understanding and experience of COVID-19 other factors associated with increased vulnerability to SARS-CoV-2 were identified, including those from Black, Asian, and Minority Ethnic backgrounds.
- In May 2020 the Faculty contributed to a consensus: Risk Reduction Framework for NHS staff at risk of COVID-19 infection , highlighting the responsibility of employers to secure, as far as reasonably practicable, the health, safety, and welfare of workers by an equitable approach to risk management and risk reduction of potential workplace hazards for all staff, regardless of ethnicity and diversity.
Risk management includes the assessment of potential exposure to SARS-CoV-2, application of a hierarchy of control measures, including safe systems of work and appropriate PPE to reduce exposure, alongside the identification of those individuals within the workforce with potentially increased vulnerability to infection.
Effective risk assessment and management should underpin decisions about safe working practices and staff deployment in all workplaces, in accordance with HSE guidance https://www.hse.gov.uk/coronavirus/working-safely/index.htm .
- PHE’s report, June 2020, Beyond the data: Understanding the impact of COVID-19 on BAME groups , based on a rapid literature review and engagement with a broad range of stakeholders, highlighted the increased risks of infection and adverse outcomes amongst those from a BAME background.
- The Office for National Statistics report, June 2020, Coronavirus (COVID-19) related deaths by occupation , showed significantly increased risks of death in certain occupations including security guards, transport workers, bus, coach and taxi drivers, care workers, chefs and sales and retail assistants – occupational groups associated with direct contact with people and also includes a higher proportion of workers from an ethnic minority background.
- Further review of surveillance data by PHE, Disparities in the risk and outcomes of COVID-19 , identified increasing age, certain geographical locations, deprivation, and comorbidities, particularly diabetes, hypertensive disease, chronic kidney disease, COPD, and dementia, alongside ethnicity and occupation as relevant to adverse clinical outcomes.
- The recent ONS report, October 2020, Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020 , showed that ethnic differences in mortality involving COVID-19 are most strongly associated with demographic and socio-economic factors, such as places of residence and occupational exposures and cannot be explained by pre-existing health conditions using hospital data or self- reported health status.
Consensus from PHE, HSE and FOM
Following the PHE report, Beyond the Data, in June 2020, the Faculty of Occupational Medicine was invited to join a multi-disciplinary cross-sector group commissioned by SAGE, to consider strategies to mitigate the occupational, workplace risks of COVID-19 for ethnic minority groups.
The consensus from this group, reflected in the statement from the Minister for Equalities on 22.10.20 is summarised below:
“The consensus from PHE, HSE and FOM on workplace risks recommends that mitigation is best addressed through consistent and effective implementation of existing Health and Safety Executive (HSE), HMG and other guidance for employers including recent guidance on SARS-CoV-2 infection.
This should apply to all workplaces, including small and medium enterprises (SMEs) which may have higher proportions of BAME staff in employment. Workplace Guidance should ensure that control measures address the risk of exposure to SARS-CoV-2, should be applied to all workers, and should take account of all relevant factors and not just a person’s ethnicity.”
Role of Occupational Physicians, OH services, Clinical Risk Stratification, Next Steps
Occupational Medicine doctors and Occupational Health (OH) services have a key role in assisting employers to keep their workforce safe. This includes strategic advice on risk assessment and risk reduction, and may include individual (confidential) clinical OH assessments where there are concerns about health or other factors which may place individual workers at greater risk from COVID-19.
Assessment of an individual’s ‘clinical’ risk related to COVID-19 may be assisted by a risk stratification approach. Several risk stratification tools are already used by OH practitioners to assist their assessments and advice to workers and employers.
The majority have been developed by, or with, specialists in Occupational Medicine. Examples are on the websites of:
NHS Employers 
Welsh Government 
All are based on the common principle of identifying potential individual risk factors and considering these alongside workplace activities and risks, social factors (e.g. transport to work), and the local epidemiology.
Development of a national, evidence based, data-driven risk prediction model, the QCOVID clinical risk stratification tool, has been commissioned by the CMO from the Oxford based Primary Care Epidemiology Group, to be available ‘to support GPs and specialists in consultations with their patients to provide more targeted advice based on individual levels of risk’ https://doi.org/10.1136/bmj.m3731 .
It is intended that this should also be made available to clinicians in Occupational Health.
The use of a national and consistent approach to clinical risk assessment related to COVID-19 has the potential to support clinical judgements in both occupational health and primary care settings. However, a number or risk score alone, from any risk stratification tool, will not provide the whole answer to decisions about work https://www.fom.ac.uk/wp-content/uploads/Coronavirus-risk-assessment-ethics-v3-FINAL.pdf .
The use of the QCOVID risk tool is likely to raise questions about work during many clinical encounters. Ideally, its use should be coupled with the facility for workers and their employers to obtain further specialist occupational medical and OH professional advice when necessary. However, access to such services is very limited.
In 2016 a report from the All-Party Parliamentary Group on Occupational Safety and Health noted that only 38% of the workforce in this country had access to OH services and only 13% to an accredited specialist in occupational medicine. The situation has not improved since then and the outcome of HMG’s consultation Health is Everyone’s Business, in 2019 is awaited.
A future public facing version of the QCOVID-19 risk stratification tool may also have value in helping individuals to consider their own risks but, without workplace risk assessment and management, will not provide all the answers for workers.
The Faculty is grateful for the collaborations and contributions to this work from colleagues and in particular to Dr Shriti Pattani and Professor David Coggon, who contributed on behalf of Occupational Medicine to the SAGE commissioned working group.
22 October 2020