| RESPONSIBILITIES FOR MONITORING AND IMPROVING THE MANAGEMENT OF HEALTH AND SAFETY
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| (a) The NHS Executive
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| Qs 87, 105
| 31. Our predecessors asked the NHS Executive what role they played in developing ways to promote improvements in health and safety. The NHS Executive replied that the statutory responsibility rested with health authorities and trusts, although the Executive had responsibilities for the overall system and value for money. They also needed to work in partnership with the professional organisations and with the trade unions who had an important part to play.
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| Qs 5-6, 42
| 32. The Executive accepted that they had not previously been aware of the disparities in accident rates, and agreed that the data did raise questions. In this situation it was not good enough to put forward the defence of devolved management, and it was reasonable for the central management of the health service to intervene. The NHS Executive stated that they did this by producing guidance, and that they had issued a lot of guidance in the past, although they accepted that this was not the whole answer.
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| Q 97
| 33. Our predecessors asked how the NHS Executive knew where the problems were. The Executive replied that they knew where the problems were at the extremes. The establishment of a national system for collecting data would take considerable time and effort, and given the limitations on resources and the way in which people worked they considered that this issue was best handled at a local level. They recognised that it needed to be well-handled at local level, but ultimately they had the backstop of the Health and Safety Executive.
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| Q 121
| 34. The NHS Executive confirmed that they accepted all of the recommendations in the Comptroller and Auditor General's Report and they would ensure that those attributed to the Executive were carried through. They also expected trusts to do the same in respect of the recommendations which they were asked to carry through.
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| Qs 36, 127
| 35. They added, that, supported by Ministers, they had six priorities for 1997-98, and good employment practice, of which health and safety was part, was one of these. In their view, this demonstrated how important they took the issue.
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| Q 8
| 36. The Executive recorded that they had already issued new guidance which brought the main tenets of the National Audit Office study to the attention of the health service. They planned to issue more considered guidance and follow-up systematically in the year ahead in the light of the Committee's hearing. All this guidance would build on the principles of risk assessment and risk management.
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| Qs 17, 62
| 37. They added that while they would not receive and monitor nationally information from trusts on trends in accidents, they expected regions to work with trusts on this issue. They planned to reinforce the message that data should be collected in a systematic way at local level, analysed for trends and action taken to make sure trusts provided a safe environment for patients and staff.
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| Qs 19, 88-90, 95
| 38. The NHS Executive said that they were looking to tackle the issues in a focused way and were developing good practice in areas in which the health service was particularly vulnerable, for example on segregation of waste and on violence in accident and emergency departments. On the latter, they were working with hospitals and professional staff to develop and disseminate good practice. They had issued guidelines on security audits and had run seminars for two members of staff from each trust in the country. Over the next two years they had the opportunity to focus also on particular institutions or parts of the country where they thought there might be problems.
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| Qs 115-118
| 39. Our predecessors asked whether the NHS Executive had considered, as an alternative to issuing more guidance and running seminars, establishing specialist teams to visit hospitals to provide the advice and help people wanted. The Executive had not thought of doing this, and believed it would be quite difficult to assemble the skills. They considered the best way to achieve better performance was in a less formalised way by creating an environment where people could sit with data and ask why it was that others did so much better than themselves. The exchange of information would come through making contacts with the successful people who would give them advice and support.
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| Qs 5, 96
| 40. Our predecessors asked why there was no push to see performance in league table terms to show how good or bad a hospital was in this area. The NHS Executive agreed that this sort of data was required but that, in their view, it was best handled at local level, in discussion between health authorities and trusts, and through a voluntary system of benchmarking. They said that within the next four to six months they expected NHS Estates to have produced a benchmarking system based on the "safe code" approach used in the National Audit Office study.
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| Qs 18, 72
| 41. The NHS Executive added that while trusts were not required to include any statement of accidents in their annual reports at the moment, the Executive would be taking up the suggestion made in the Comptroller and Auditor General's report to put trusts more on the spot in terms of public reporting.
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| C&AG's Report, paras 1.23 to 1.25
| 42. Fifteen per cent of the staff accidents recorded in the National Audit Office study involved manual handling, the majority occurring during the lifting and moving of patients. The main type of injury was back strain. Such injuries may involve long term sick leave or even retirement on ill-health grounds. In view of the research in one trust which showed how the number of days lost from back injuries could be reduced, our predecessors asked the NHS Executive what responsibility they had for ensuring effective research into the costs and benefits of action to improve health and safety.
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| Q 20
| 43. The Executive stated that there were research projects on the treatment of back injury, and there were preventative measures drawn from the appropriate legislation on manual handling which they pursued through guidance. The dramatic improvements in the example quoted were repeated in other parts of the NHS. However, good practice was not universal and they needed to keep striving to ensure that best practice spread across the country.
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| Qs 69, 71, 95
| 44. Our predecessors asked what training was given to staff in manual handling. The NHS Executive replied that there were standard training guidelines and techniques which ran right through from the nurse education system and the education system for other groups like ambulance drivers, paramedics and physiotherapy. The important thing was to ensure that training was constantly topped up. There was also national work in developing good practice. In addition to the advice and training they considered two other things were needed. One was very clear procedures and the other was to ensure that the best physical surroundings and the best equipment were available to assist manual lifting.
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| (b) Health authorities and NHS trusts
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| Qs 21, 112-113
| 45. Our predecessors asked who was responsible in a typical trust for the health and safety of their employees. The NHS Executive stated that the trust board itself was ultimately responsible. Within the board, the chief executive had very important responsibilities in relation to the whole panoply of legislation and it was often the case that one non-executive member took an interest. Beyond that, there would usually be a director of operations who carried day to day responsibility delegated by the chief executive. Other members of staff would have specific geographical responsibilities within the hospital site or responsibilities linked with their special interests and expertise. Line managers also had a general responsibility to make the system work.
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| Qs 110, 126
| 46. The NHS Executive accepted that trusts might not have been paying enough attention to this issue and that it was one they had to focus on. For example, one of the trusts in the National Audit Office study, Royal Liverpool, now had health and safety as an item at every board meeting. The Executive added that while many boards would have set their chief executives and senior staff specific targets for improving performance on health and safety issues, the Executive could not instruct them what to do.
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| Evidence pp 1-2,
| 47. In their submission, UNISON told the Committee that reports they received from many of their safety representatives in the health service suggested that when they raised issues or identified hazards they were often ignored. They also received complaints that safety committees were used just to rubber stamp policies rather than being an open forum, and at many work places employer representatives were drawn from lower tiers of management and did not have the power to deal with many issues.
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| Q 105
| 48. The NHS Executive agreed that safety representatives were very important in raising issues of concern as they were often the people with the best intelligence of what was going on on the ground. Managers needed to be in touch with that level of detail. In their own guidance in 1994 the NHS Executive had drawn attention to the need for safety committees and the importance of safety representatives' involvement in these committees. Any guidance about good practice should underline the question of staff involvement.
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| Qs 6, 62, 74-75
| 49. The NHS Executive added that purchasers had the important lever in their role as the customer. Health authorities had a responsibility for the quality of services provided in their trusts and to ensure that trusts were pursuing best practice. They should be pursuing this issue through their contractual relationships with trusts. If purchasers were faced with increasing costs, or hoped to reduce current costs, they should be asking searching questions about, for example, staff absence levels and manual lifting. If there was a run of incidents where people had fallen, or there had been difficulties in a particular part of the hospital, they would want to know that these things had been put right.
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| Evidence, Appendix 1pp 21-29
| 50. Finally, our predecessors asked what follow-up action had been taken in the 30 trusts involved in the study. The NHS Executive confirmed that each of the trusts had made very important progress and in a subsequent note they provided detailed reports on the action taken.
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| Conclusions |
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| 51. We consider it essential that hospitals should be made safer places to be treated in, to work in, and to visit. We welcome the high priority which the NHS Executive have given to health and safety issues in 1997-98 and their pledge to act on all of the recommendations contained in the Comptroller and Auditor General's report. We note the action taken in the trusts visited by the National Audit Office and District Audit to put in place improvements in their recording and management of health and safety. We look forward to seeing further significant improvements in performance across all NHS trusts over the next year.
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| 52. We note that the NHS Executive are seeking better collection and analysis of data on accidents at local level coupled with voluntary benchmarking of trusts' performance. We see these as important and helpful mechanisms in helping trusts to assess and to improve their performance. However, we are doubtful whether it is sufficient to rely on voluntary benchmarking in this important area, and we look to the NHS Executive to explore ways of ensuring that all trusts participate. We also expect the NHS Executive to consider ways of re-inforcing accountability, for example by requiring trusts to include reports on their health and safety record in their annual reports and through the publication of national league tables of performance.
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| 53. We note the work under way by the NHS Executive in developing further guidance on good practice, focusing on areas where the health service is particulary vulnerable. We also note that their guidance in the past has had limited effect. We therefore urge the NHS Executive to consider alternative ways of securing greater awareness and the implementation of good practice, for example by setting up a small team of experts to visit trusts to provide on the spot practical advice.
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| 54. We note that some trusts have found cost-effective ways of reducing the number and costs of accidents in areas such as manual handling. We look to the NHS Executive to consider how best to promote and disseminate more effectively research on the costs and benefits of action to improve health and safety.
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| 55. We note the Executive's view that trust boards have not been paying sufficient attention to health and safety issues. We expect trust boards to take stock of their oversight of this important area, and to promote health and safety as a key priority for action. For this to be fully effective, boards will need to involve staff and the professional organisations in considering how health and safety in their hospitals can be improved.
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| 56. We note that healthcare purchasers have a key role to play in securing improvements in trusts' performance on health and safety. We expect all health authorities to review the health and safety performance of the trusts with whom they contract, and to include health and safety targets in their contracts with trusts.
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