Examination of Witnesses (Questions 20
MONDAY 12 MAY 2003
Q20 Mr Rendel: What I am asking is
are all PCTs providing some money to provide that service, or
using some of that money to provide that service?
Sir Nigel Crisp: I am afraid I
do not know that answer and it was not covered specifically in
that way within this Report.
Q21 Mr Rendel: No, it was not.
Mr Foster: The standard that I
was talking about, the Improving Working Lives Standard, which
did require NHS trusts to have occupational health service available
by 31 March of this year, the same target is set for PCTs by 31
March next year.
Q22 Mr Rendel: Anyway, you have not
yet said that they have not used any of that money for providing
a service, only by the beginning of next year?
Mr Foster: They have to demonstrate
that they have reached that target by the end of this financial
Q23 Mr Rendel: Do you know how many
Mr Foster: I cannot answer that
at the moment, no, I am sorry.
Q24 Mr Rendel: Is it possible to
provide a note about it? Have you had that information?
Mr Foster: I am not sure whether
we have had the information, but if we have, sure we can let you
Sir Nigel Crisp: We can provide
you with a note telling you where we are and when we will have
Q25 Mr Rendel: Okay. Thank you. Doctors,
we are told, are the worst of all of the staff at reporting accidents.
That seems to me to be quite a fundamental point, in that one
would expect them to be, if anything, setting an example with
other staff. What are you doing in particular to try to persuade
the doctors in the NHS staff to announce when they have had an
accident which is reportable?
Mr Foster: This is very much a
matter for local management and national guidance. There are some
particularly good examples. I mention the Hammersmith Trust which
has got an Intranet, which makes it remarkably easy to record
a clinical incident by simply drawing up a form on the Intranet
system and that is done to make it far easier to report these
incidents. I think one would expect as part of the Improving Working
Lives Strategy that one asks all types of staff what their experiences
are of meeting the various criteria including improving health
and safety at work and that would include meeting groups of doctors.
They are intended to be embraced in the same way.
Q26 Mr Rendel: Do you have any sort
of sanction if you find out after the event that somebody has
not reported what is obviously a reportable accident under health
and safety legislation?
Mr Foster: Under health and safety
legislation I cannot imagine that it is a criminal offence. I
would imagine that what most trusts do is have internal reporting
procedures which will lay down the clear responsibility on all
members of staff to report incidents.
Q27 Mr Rendel: What happens if they
do not? As I understand it the NAO found that something like 60%
of those accidents attributable are not being reported. That is
a hell of a whack. There must be at least some occasions on which
that has later come to light and an accident, as it happens, has
not been properly reported, although I am wondering what then
happens to the member of staff there?
Mr Foster: I think it would be
using a hammer excessively to invoke the disciplinary procedures
unless there is some really gross negligence involved, but this
is very much something that we would leave to local organisations
to use their common sense.
Q28 Mr Rendel: What action is taken?
I am not necessarily saying they have to be stopped from being
a doctor or stopped from being a nurse or whatever. If we just
leave it that reportable accidents are not recorded and nothing
ever happens, then it seems to me that there is every incentive
not to report accidents, not least because it might be damaging
to the person's career if they have an accident which it might
be felt they caused to themselves?
Sir Nigel Crisp: Okay. As I understand
it there is no legal sanction that is taken, but what can be taken
is anything to do with the trust disciplinary procedure, which
can range from counselling to whoever is in charge of the department
pointing out to people what they should be doing.
Q29 Mr Rendel: Does that happen?
Are these procedures being put in place?
Sir Nigel Crisp: I have to say,
I do not know anecdotally of specific instances of that, but that
is the sanction that would be used. It is just the normal employment
process within the trust.
Q30 Mr Rendel: Although some 60%
of accidents are not being reported, you do not know what action
is being taken?
Sir Nigel Crisp: I have to say
the professional bodies as well are also encouraging reporting,
so the BMA and others also are encouraging reporting, so there
is a lot of pressure.
Q31 Mr Rendel: It seems surprising
that if as many as 60% are not being reported, one needs to decide
more about it, not least because, as I say, if the main source
of non-reporting is coming right from the top, then you are hardly
going to get more junior members of staff reporting it. Nothing
is being done and the senior members of staff are found not to
Mr Foster: Yes, but typically
this is what a Controls Assurance audit would attempt to pick
up. It would scrutinise a department, find out what the level
of non-reporting is, try and identify where the non-reporting
is not taking place and then add to the local policies, whether
it should be a counter-checking procedure. It is very much a local
issue as to how you implement your own policies.
Q32 Mr Rendel: Have you set targets
for how many such accidents should be reported in future so that
you can notice whether they have increased from the 40% or gone
Sir Nigel Crisp: Only in as much
as we have a policy that they should be reported. We have not
set particular targets as milestones towards 100% reporting, no.
Q33 Mr Rendel: Would that not be
a good idea? It seems to me that the level is really part of the
argument. I cannot help feeling that if only 40% are being recorded,
that is not a very good figure.
Sir Nigel Crisp: Yes. The way
we are trying to approach it, as Mr Foster has said, is making
sure that we have got the mechanisms in place. The two review
mechanisms we use are the one around Improving Working Lives and
the Controls Assurance mechanisms, which do review what is happening
in the trust and report to the trust board for the trust board
to take action.
Q34 Mr Rendel: Can I ask what work
you are doing to get better estimates of the costs to the NHS
of the accidents and ill health that are happening operationally
Sir Nigel Crisp: Yes. Again, in
a sense, as I replied to the Chairman earlier, there has been
relatively little work at this stage in looking at that. We have
asked trusts to do it. As you know from the previous report, some
trusts have done work on costing the impact of lapses in health
and safety. We will now be re-invigorating that in association
with the Health and Safety Executive and others and, as I say,
better able to do it because we will have a decent staff record
which we can work with.
Q35 Mr Rendel: Presumably you will
not really have a handle on what you ought to be doing or how
much work you ought to be doing to try to prevent accidents involved
in operational terms until you know just what it costs. There
must be some sort of a payoff here, is there not?
Sir Nigel Crisp: This is precisely
the point about why we need to get a better handle on costs. As
you will have seen within this Report we have set certain priorities,
which are the obvious ones around backpain and so on, in order
to make sure we tackle them and we have seen reductions in those.
We do now need to move on, and I particularly accept the point,
to getting as good a handle on costs as we can. It is difficult,
it is not an easy issue and quite a lot of the studies on costs
have been really quite difficult in terms of all of the different
aspects of coming to it.
Q36 Mr Steinberg: On reading the
Report it seemed to me that, in fact, most NHS trusts had taken
the topic quite seriously, not simply because of the figures that
are given in the Report. 94% of trusts have computerised systems
and probably 4% of the trusts have data recording systems which
will not be as good, but at least they do some things with that.
So that is what, 98% of the trusts who do something? However,
the Report did seem to indicate that the performance of the trusts
did vary considerably in terms of the comprehensiveness of how
they report accidents and consistency with how they did it. That
has got to be worrying, has it not?
Sir Nigel Crisp: Yes.
Q37 Mr Steinberg: How do you think
you could bring in a standard level of performance that should
be the backbone of the NHS?
Sir Nigel Crisp: Yes. Now, I absolutely
agree with you. If you look at the results of this Report compared
with the one of six years ago, there have been enormous moves
forward. What it has revealed is precisely the point you make,
which is that there are people doing it well and there are too
many laggards, so how do we deal with the laggards? The two policies,
which are the universal policies, are the ones of the Improving
Working Lives Standard which people are signed up to and then
monitored on; that is the first base and that is the external
monitoring. The second one is the whole Controls Assurance process
which requires, for example, health and safety to be reported
to the board on a regular basis and there is plenty of evidence
that is now happening. Also, the other thing though that we have
done and which we will continue to do, is to work with the Health
and Safety Executive about targeting particular areas, or indeed
particular trusts. The whole relationship with the Health and
Safety Executive has moved on enormously, again, in the last six
years, so that we can start to think about: "Well, how are
we going to target the outliers effectively"?
Q38 Mr Steinberg: Yes. Also, again,
which is slightly worrying, is the fact that some groups do not
or seem to refrain from reporting. David mentioned the doctors
and that does not surprise me at all, I have got to say. If you
remember we did a report recently on the side effects of some
medicines, is that right? If I remember rightly doctors had to
fill in a form if there was a side effect. Even though they had
forms on the desk
Sir Nigel Crisp: This was around
clinical negligence, was it not?
Mr Burr: The Medicines Control
Sir Nigel Crisp: Yes.
Q39 Mr Steinberg:they failed
to do that. Here, again, we see that they have failed to report
accidents. It seems to me that the only time they ever fill a
form in is if they are getting paid for it; they are quite keen
to do it then. I have just paid £15 for getting a doctor
to fill in two little boxes but never mind. It makes one a little
bit cynical. It seems to me to be the same here. I have not declared
any interests. However, there was a stage when I was going to
be a doctor, but I did not have patience. Why do we treat doctors
with kid gloves? If they fail to report an accident and something
comes of it, action should be taken against them should it not,
really? Obviously, I do not want to pursue the point.
Sir Nigel Crisp: Yes. There are
two or three things that are different. This Report does not break
down the difference between, if you like, the permanent staff
of the hospital and doctors in training who will rotate through
the hospital. One of the issues for us within hospitals, which
we are getting better at, is making sure that the doctors who
are there only for six months, or 12 months, or 18 months understand
the policies of the hospital are part of the induction programme
and understand how you do these things and so on. I think that
is one point which distinguishes doctors in general from others,
but your general wider point about employees of an organisation
should behave equally as all other employees and, indeed, many
do. Again, I think the other point that Mr Foster made was we
need, of course, to make it easier for people to report.
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