responsible for the care of the patient in the operating theatre. The new type of consent form might actually cause the confusion that it was intended to avoid, in particular if a surgeon explains to a patient the nature and effects of general anaesthesia when the anaesthetist had planned a local or regional block. An extra paragraph needs to be added for the anaesthetist to obtain consent for and explain the anaesthetic technique proposed. For example, in some units a separate consent is obtained by the anaesthetist when an epidural nerve block is inserted for pain relief or surgery in obstetric practice. P J G HUTCHINGS A BOND

G FISHER P HUTTON D STOKES

Queen Elizabeth Hospital,

Birmingham B 15 2TH 1 Delamothe T. Consenting patients. BMJ7 1990;301:510.

(15 September.)

SIR,-Dr Tony Delamothe reports that the NHS Management Executive has issued new consent forms. The clear presentation and straightforward English used in the proposed form is welcome. I am concerned, however, that in the notes to patients section the form states that "You may refuse any involvement in a formal training programme without this adversely affecting your care and treatment." In many departments in the NHS there will be a delay and prolonging of the patient's disability if treatment is not performed by a doctor who is training. Until the number of consultants aimed at in Achieving a Balance is attained the wording in this form should be altered.

than among Swiss workers in 1982. Thus in Switzerland the data based only on nationals would report a more favourable health profile for construction workers than is the case.6 This difference may also apply to other countries in which migrant workers are employed in the construction industry. The problems in estimating the extent of the detrimental health effects of working in the construction industry make it difficult to establish the particular causes. Dr Snashall suggests that "the industry attracts feckless men who enjoy an irregular, physical outdoor life and danger." The reference that supports this assertion is to a study of the behaviour of roofers'-who might be considered an extreme group in this regard. In the decennial supplement for the years around 1981 there is a 10-fold increase in the mortality due to falls from high places among roofers.3 This is not unexpected and probably reflects the risks of the job rather than the behaviour of the workers. Similarly it would be wise to examine the true extent and effects of what Dr Snashall refers to as "the abuses that an all male work force living away from home seems to indulge in" before deciding that much of the excess poor health is not directly

occupational. A European Community study found that the increased risk of fatal accidents varied widely among countries (table).8 The British policy, with regulations being issued and supervised by a central body, is not succeeding. The enforcement of safety regulations should be supervised by local bodies, with effective representation of workers. Relative risk offatal accidents among construction workers compared with workers in manufacturing industry Relative risk

DAVID LAWS

Birmingham and Midland Eye Hospital, Birmingham B3 2NS 1 Delamothe T. Consenting patients.

BMJf 1990;301:510.

(15 September.)

Safety and health in the construction industry SIR,-Dr D Snashall's editorial highlights the

problems of poor safety and health in the construction industry' and notes that there are difficulties in collecting and interpreting health data regarding

construction workers. Data on occupational mortality in Britain are available from the decennial supplements.2" The occupational coding used for construction workers, however, does not include the many labourers who work on the "lump" system and are hired and fired as work becomes available. This group of casual workers are likely to have the jobs most damaging to health. Thus the raised standardised mortality ratios for various causes of death reported for building and construction workers in the decennial supplements underestimates the high mortality in this group as a whole. Routine data sources do not generally include migrant workers, who may experience the worst conditions of work. Information on migrant workers is, however, available in Switzerland, a country in which 67% of workers in the building trade were foreign nationals in June this year.' Most migrants are seasonal workers and are allowed to work in Switzerland for no more than nine months a year. They need permission from local authorities and from their employers if they want to change their place of work. Clearly their legal status is difficult, and they are thus likely to experience the worst conditions of work. The risk of serious accidents, requiring at least three days off work, was 45% higher among foreign nationals

932

Italy United Kingdom

70 4-5

France

4-2 3-4 2-5 2-2

Belgium The Netherlands

West Germany

West Germany and The Netherlands have policies closer to this ideal, which may explain the lower excess in mortality among construction workers in these countries. Improving the health and safety of construction workers clearly requires structural changes. Yet Dr Snashall's plea for employers' federations to get together with trade unions to lobby the government sits uneasily with the reaction of the employers in 1972 when a concerted effort was made by building workers to end the "lump" system of insecure casual labour. Several trades unionists ended up in prison, and the legacy of 1972 is reflected in the fact that the building industry still relies on this pernicious and health damaging system. GEORGE DAVEY SMITH London School of Hygiene and Tropical Medicine, London WC1E 7HT

MATTHIAS EGGER University of Berne, 3010 Berne, Switzerland

DAVID BLANE

Charing Cross and Westminster Medical School, London W6 8RP 1 Snashall D. Safety and health in the construction industry. BMJ 1990;301:563-4. (22 September.) 2 Office of Population Censuses and Surveys. Occupational mortality 1970-1972. London: HMSO, 1978. 3 Office of Population Censuses and Surveys. Occupational mortality, decennial supplement 1979-1980, 1982-1983. London: HMSO, 1986. 4 Schweizerischer Baumeisterverband. Quartalsstauistik. Zurich: Schweizerischer Baumeisterverband, 1990. 5 Burkhalter R. Arbeitssicherheit, Arbeitsgestaltung und Technologische entwicklung im Baugewerbe. Berne: Schweizer Nationalfonds, 1988. 6 Egger M, Minder CE, Davey Smith G. Health inequalities and migrant workers in Switzerland. Lancet 1990;336:816.

7 Barry and Associates. Behavioural analysis of workers and job hazards in the roofing industry. Cincinatti, Ohio: Department of Health Education and Welfare, National Institute of Occupational Safety and Health, 1975. 8 Eisenbach B. Bewertung und Vergleich vorhandener Daten und Bezugsgrossen zur Bestimmung der Arbeitsbedingungen in der Bauindustrie in den Landern der Europaischen Gemeinschaft. Dortmund: Bundesanstalt fur Arbeitsschutz und Unfallforschung, 1981.

SIR,- Dermatologists are repeatedly disappointed that the scale and degree of disability resulting from occupational dermatitis is ignored so often. Indeed, dermatitis was not mentioned in Dr D Snashall's editorial on the construction industry.' Studies indicate that cement dermatitis could account for 20-40% of all cases of occupational dermatitis,2 and in 1965 up to 200000 working days were lost in Great Britain because of dermatitis.' These statistics surely deserved some comment. The scale of the problem in this country is difficult to assess as, regrettably, no figures have been kept on occupational dermatitis by any statutory body since 1981. When figures were kept occupational skin disorders from all sources accounted for well over half the working days lost because of prescribed diseases in England and Wales. Failure to collect data on occupational dermatitis results in an inability to recognise occupational skin hazards, and as a result no appropriate steps can be taken to assess.these and evaluate preventive measures. As a start the Health and Safety Executive are funding a pilot study enabling the British Contact Dermatitis Group to take a preliminary look at the problem, but we still have a long way to go before an accurate record of the extent of occupational dermatitis is recorded in this country. The failure to identify the extent of such an important cause of occupational morbidity emphasises the truth of Dr Snashall's assertion that British industry is badly served by its occupational health infrastructure. I would respectfully request that a higher profile is given to the commonest of all industrial diseases in future articles on occupational health. MICHAEL H BECK Contact Dermatitis Investigation Unit,

Salford, Lancashire M60 9EP 1 Snashall D. Safety and health in the construction industry. BMJ

1990;301:563-4. (22 September.) 2 Cronin E. Contact dermatitis. Edinburgh: Churchill Livingstone,

1980:300. 3 Burrows D, Calnan CD. Cement dermatitis 2. Clinical aspects.

Transactions of St John's Hospital Dernatological Society 1965;51:27-39.

Death by 1000 cuts SIR,-Dr Alison Walker stated that Oxford is dealing with a £1-4 million deficit but has not had to close any beds. ' This is quite untrue. One of our two medical paediatric wards was closed for the four months from mid-January to mid-May. A ward was closed again for the whole of August. Currently we have only three quarters of our medical paediatric beds open and half of our paediatric intensive care beds closed. I wonder if you could let me know who gave you this misleading information so that I can let whoever it was know the truth. M W MONCRIEFF

John Radcliffe Hospital, Oxford OX3 9DU 1 Walker A. Death by 1000 cuts: 11 Oxford. BMJ 1990;301:358. (18-25 August.)

***The district health authority was telephoned, and a spokesperson denied any bed closures for financial reasons. -ED, BM7. BMJ VOLUME 301

20 OCTOBER 1990

Safety and health in the construction industry.

responsible for the care of the patient in the operating theatre. The new type of consent form might actually cause the confusion that it was intended...
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