The Milking Stool

“If a worker fractures their leg at work, we report it. If they develop post-traumatic stress disorder after repeated exposure to traumatic events, we usually do not report it.”

That single contrast raises uncomfortable questions, not because psychological injury is necessarily easier to diagnose than physical injury, nor because every case of work-related stress should be reportable. Rather, it highlights something far deeper.

How do we determine what counts as workplace harm?

The Health and Safety Executive’s consultation on proposed changes to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 offers an opportunity to consider that question.  At first glance, the consultation appears to focus on technical changes: updating the list of reportable diseases, clarifying dangerous occurrences, and modernising reporting requirements.  Yet beneath those proposals lies a broader debate about diagnosis, professional competence, occupational disease, and whether our systems still reflect contemporary understandings of work-related harm.  For those working in occupational health, organisational psychology, health and safety, and human factors, the consultation offers an opportunity to think beyond reporting rules.  It invites us to ask three interconnected questions:

• What counts as workplace harm?
• Who is competent to recognise the harm?
• How should reporting systems support prevention efforts?

RIDDOR has always focused on prevention

Although often seen as a legal reporting requirement, RIDDOR serves a much broader purpose.  Reporting helps patterns to emerge.  It enables regulators, employers and practitioners to identify hazards, investigate their causes and prevent future harm.  The value of RIDDOR has never been the paperwork itself.  Its value lies in making workplace harm visible.

• What organisations count, they investigate.
• What they investigate, they seek to prevent.

This simple principle is important when considering both occupational disease and psychological injury.

A welcome shift towards occupational disease

One of the most encouraging aspects of the consultation is its increased emphasis on occupational disease.  Historically, workplace safety has focused heavily on accidents and acute injuries.  Today’s workforce increasingly experiences harm from chronic exposure to cumulative hazards and diseases that develop over months or years rather than in minutes.  Expanding the list of reportable occupational diseases is an important recognition that prevention must address both illness and injury.  However, this raises a further quandary ….

Diagnosis is central to prevention.

Every reportable occupational disease is first diagnosed clinically.  For many prescribed diseases, employers are legally obliged to report only after an appropriate diagnosis has been made, and the disease is considered likely to have arisen from specified work activities.  This requires considerably more than recognising symptoms.  Clinical diagnosis is among the most complex activities in healthcare.  It involves integrating information from the clinical history, physical examination, diagnostic investigations, epidemiology and disease mechanisms, while considering competing explanations and managing diagnostic uncertainty.  The knowledge and skills required include:

• clinical reasoning;
• differential diagnosis;
• interpretation of investigations;
• physical examination;
• understanding occupational causation;
• recognising diagnostic bias;
• managing uncertainty.

These competencies differ from many of those that define occupational health practice, including health surveillance, rehabilitation, case management, workplace assessment, and advising employers.  All are essential, but they are simply different.

Competence matters more than a professional title.

The consultation proposes widening the range of healthcare professionals who can trigger reporting. This reflects contemporary multidisciplinary occupational health practice.

Occupational health services increasingly rely on multidisciplinary teams, with different professions contributing complementary expertise. Occupational health nurses are often the first clinicians to identify possible work-related illness and to coordinate assessment and ongoing management, while occupational physicians provide specialist expertise in medical diagnosis, occupational disease and work-related causation. As roles continue to evolve and advanced practice expands, the focus should remain on ensuring that clinicians undertaking diagnostic decision-making have acquired the necessary knowledge, skills, supervised experience and governance for that aspect of practice.

This should not become a debate about professional territory. Rather, it is a question of patient safety and clinical governance. Competence cannot be assumed simply because someone holds a particular professional registration, nor should it be dismissed because they hold another. Increasingly, healthcare is moving towards competency-based practice, where capability is determined by demonstrable knowledge, skills and experience rather than professional title alone. Occupational health should be no different.

For competency-based practice to work, however, those competencies must also be visible. Employers, workers, regulators and occupational health services need clear, easily understood ways to recognise, demonstrate and communicate the competencies required for different aspects of practice, particularly where diagnostic decision-making has significant clinical, legal and occupational consequences. Equally important is the ability to demonstrate how those competencies have been achieved, assessed, maintained and supported through appropriate clinical governance.

Why getting the diagnosis right matters

Diagnostic accuracy affects far more than regulatory reporting.  Workers may face delayed treatment, prolonged exposure to hazards, inappropriate employment decisions, missed workplace adjustments, or reduced access to rehabilitation.  Employers may fail to identify workplace hazards or to implement appropriate preventive controls.  National surveillance data may become less reliable.  Ultimately, an inaccurate diagnosis undermines prevention.

What remains invisible?

Yet perhaps the most striking aspect of the consultation is not what it contains, but what remains outside the reporting framework. RIDDOR continues to exclude most forms of psychological injury. There is generally no requirement to report on:

• work-related stress;
• depression;
• anxiety disorders;
• burnout;
• adjustment disorder;
• moral injury;
• post-traumatic stress disorder arising from workplace exposure;
• psychological injury associated with bullying or harassment.

This creates an interesting paradox.  A worker developing occupational asthma after chemical exposure may trigger statutory reporting.  A healthcare worker developing severe depression after sustained moral distress does not.  A police officer developing PTSD after repeated exposure to traumatic incidents does not.  A nurse experiencing profound burnout after a prolonged, excessive workload does not.  This is not because these conditions are unimportant.  It is because they fall outside the current reporting framework.

Does complexity justify exclusion?

The obvious argument is that psychological injury is difficult to diagnose and even harder to establish causation in the workplace.  There is truth in that.  Mental health conditions almost always have multiple interacting causes.  Yet many recognised occupational diseases are also characterised by diagnostic uncertainty.  Occupational asthma, dermatitis, hearing loss and upper-limb disorders often require clinicians to weigh competing explanations, interpret investigations and consider both occupational and non-occupational influences.  Complexity has never prevented occupational medicine from developing robust diagnostic approaches.  Perhaps complexity alone should not determine whether psychological harm remains invisible.

Employers still have responsibilities.

The absence of psychological injury under RIDDOR should never be taken to mean there is no legal responsibility. Employers continue to owe duties under the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and common law. Psychosocial hazards require assessment and control, just as physical hazards do. Excessive workload, bullying, low job control, poor organisational support, traumatic exposure and moral distress are legitimate workplace hazards. Increasingly, the evidence supporting this is difficult to ignore.

What gets measured gets managed.

One consequence of the current framework is that organisations often develop sophisticated systems to monitor physical safety while collecting comparatively little information on psychological harm.  Many boards receive regular reports on:

• RIDDOR incidents;
• lost-time injuries;
• accident rates;
• dangerous occurrences.

Far fewer routinely receive equivalent information regarding:

• psychosocial hazards;
• psychological safety;
• work-related stress;
• burnout;
• bullying and harassment;
• cumulative traumatic exposure.

This matters because reporting systems shape organisational attention.  If harm is visible, organisations investigate it.  If it remains invisible, learning opportunities are easily lost.

Beyond compliance

The consultation, therefore, represents much more than an opportunity to amend reporting regulations.  It invites a broader conversation about how occupational health, health and safety, and organisational governance understand workplace harm.  Rather than asking only:

“Should this condition be reportable?”

Perhaps we should also ask:

• What forms of workplace harm remain hidden?
• What competencies are required to recognise them?
• How should multidisciplinary teams work together to identify them?
• What information best supports prevention?
• How can physical and psychological safety be understood as parts of the same organisational system?

These are governance questions every bit as much as regulatory ones.

The future of occupational health

Occupational health has always been multidisciplinary.  Occupational health nurses, physicians, psychologists, physiotherapists, ergonomists, human factors specialists and safety professionals each contribute distinct expertise.  The challenge is not deciding which profession matters most.  It is ensuring that every professional practises within demonstrable competence, that governance supports high-quality diagnostic decision-making and that organisational systems recognise the full spectrum of workplace harm.  Ultimately, prevention depends on two things:

• First, recognising harm accurately.
• Second, deciding that every form of preventable harm deserves to be seen.

Perhaps the biggest opportunity presented by the RIDDOR consultation is not simply to modernise reporting requirements, but to rethink how we define workplace harm, how we recognise it, and how we ensure that no worker’s injury—whether physical or psychological—remains invisible simply because our reporting systems have yet to catch up with contemporary evidence.