Select Committee on Public Accounts Forty-Second Report


1. In 1997 our predecessor Committee's Report on Health and Safety in NHS Acute Hospital Trusts in England highlighted the need to improve the recording of health and safety incidents in the NHS, including staff accidents. They were concerned that staff accidents imposed a significant burden on resources which could be better spent on patient care. They found it unsatisfactory that many hospitals did not have robust accident recording systems, that there were very wide differences in accident rates, and difficulties in making comparisons because of under-reporting. They recommended that chief executives and boards should take a stronger lead in encouraging staff to report all accidents promptly.[2]

2. In response the Department launched a number of initiatives, including issuing guidance to NHS Trusts to put in place policies and procedures to record, monitor and assess the causes and costs of accidents, sickness absence, ill health retirements and occupational ill health for all health and safety risks. The Department emphasised that trust chairs and chief executives should make health and safety a priority area.[3]

3. One key initiative, launched in September 1998 by the then Secretary of State for Health, was Working Together Securing a Quality Workforce for the NHS. This heralded a new approach to the management of human resources in the NHS and gave a commitment to measuring progress against a range of process and outcome targets. Subsequent guidance issued in April 1999 set national improvement targets for reducing sickness absence, accidents and violence and aggression by 20% by 2001 and 30% by 2003. The targets were subsequently incorporated in the Improving Working Lives standard, launched in October 2000, which all acute, mental health and ambulance trusts were required to put into practice by April 2003.[4]

4. On the basis of a follow-up Report by the Comptroller and Auditor General we took evidence from the Department to determine the extent to which the national improvement targets have been met and the impact that accidents have on acute, mental health and ambulance trusts; the adequacy of the strategic management of health and safety risks, including the management of risks to agency and contract staff; and the effectiveness of training and other actions aimed at reducing the extent and impact of accidents. Our earlier Report, Protecting NHS Hospital and Ambulance Staff from Violence and Aggression (39th Report, Session 2002-03), considered the related issue of the accuracy of the measurement of violence and aggression, and the effectiveness of actions taken to improve the protection and support given to healthcare staff.[5]

Failure to achieve the Working Together targets

5. In 2000-01 there were 108,743 reported accidents, a 10% decrease compared with the number reported in 1998-99 when the Working Together initiative was launched. However, the number of reported accidents in 2001-02 increased to 135,172 and as a result the national improvement target of a 20% reduction by March 2002 has not been met. Indeed there has been a 24% increase over the 2000-01 baseline figure (Figure 1).[6]Figure 1: Accidents to staff in 2001-02 compared with 1998-99 and 2000-01

Type of NHS Trust
1998-99 Estimated number of reported accidents per 1,000 staff per month
2000-01 Number of reported accidents per 1,000 staff per month (NHS baseline)
2001-02 Number of reported accidents per 1,000 staff per month (first improvement target)
N/A (iv)
Community/mental health
Mental health/learning disabilities
All NHS Trusts
Total number of accidents
120,474 (i)
108,743 (i)
135,172 (ii)
Staff accidents reported to the Health and Safety Executive (iii)

Source: National Audit Office Report[7]

(i)Information derived from Department of Health surveys conducted in 1998-99 and 2000-01. 2000-01 being the baseline for measuring the national improvement targets against.
(ii) NAO and Department of Health census of all acute, mental health and ambulance trusts to asses the position at the first milestone.
(iii)  Information provided to the Health and Safety Executive on incidents that resulted in more than three days off work. While the figure for 2001-02 is a provisional figure, like the other figures provided it is likely to be an under-estimate as in general only 42% of all incidents that should be reported to the Health and Safety Executive are reported.
(iv) Multi service trusts and community/mental health trusts are no longer a designated type of trust as services have been re-configured into either a mental health trust or a primary care trust.

6. Overall, only 23% of trusts met the 20% improvement target and, in each of the different types of trust, the number of accidents per 1,000 staff has increased compared to the 2000-01 baseline level, with ambulance trusts having the highest level of accidents per 1,000 staff. Understanding the reasons for the increase between the baseline and 2001-02 is complicated by a number of confounding factors. Some NHS trusts have seen a fall in the number of reported accidents, due to improved training and practices, while others have recorded an increase, due to increased awareness and compliance with reporting requirements. Over a fifth of trusts identified staff shortages and increased workloads as leading to poor compliance with good practice, resulting in an increase in accidents.[8]

7. The Department acknowledged that it is difficult to be precise about the reasons for the increase but believed that it was mostly due to improved reporting. They drew attention to the decline in the number of major accidents, which must by law be reported to report to the Health and Safety Executive.[9]

8. The Department had put in a large amount of effort into reducing major accidents, in particular the reduction of serious accidents due to moving and handling. (Figures provided by the Health and Safety Executive confirm that moving and handling injuries have fallen steadily since 1998). There were a number of reasons for this decrease, including targeted work by the Department, such as their Back to Work campaign; the fact that the Health and Safety Executive had concentrated on this issue during inspection visits; and that initiatives by the Royal College of Nursing and the National Back Exchange, had helped raise the profile of this issue.[10]

9. Nevertheless the March 2002 target has not been met and the Department agreed that they were unlikely to meet the March 2004 target. The Department conceded that these were stretching targets. They were also aware that there would be methodological problems because of the inadequacies of NHS trusts' reporting systems.[11]

Variations remain in the quality and comprehensiveness of information

10. Despite evidence that trusts have taken this topic quite seriously, with improvements in the levels of reporting and 94% of trusts investing in computerised data recording systems, the performance of trusts still varies considerably in terms of the comprehensiveness of reporting of accidents and the consistency in what is reported. In particular evidence from staff surveys and other research indicates that:

11. The Department assured us that the introduction of monitoring as part of the Improving Working Lives standard and the Controls Assurance process, which for example requires health and safety to be reported to the board on a regular basis, is starting to improve reporting standards. Some trusts, like the Hammersmith Hospitals, use a simple form on the Intranet which makes it easy to record accidents, and most trusts have review mechanisms in place to try and identify where non-reporting is taking place. Professional bodies also encourage staff to report accidents. Trusts can use their local disciplinary procedures against staff who repeatedly fail to report, but this would be seen as a last resort and the Department did not know of any specific instances where this has been used. [13]

Few trusts have a robust understanding of the impact of staff accidents

12. Following our predecessor Committee's Report in 1997, the Department issued guidance to trusts asking them to evaluate and improve their understanding of the costs and impacts of accidents. Few trusts have made any progress in quantifying the human and financial costs. Only 24 trusts (9%) had attempted to estimate their costs and of these only 17 provided any cost information. In the absence of robust data the NAO estimated that the annual direct cost of health and safety accidents in 2001-02 was at least £173 million.[14] The new Electronic Staff Record, which the Department expects to have in place very shortly, would give more information about staff and provide trusts with more effective access to the details of staff absence and related information.[15]

13. The only published Departmental cost estimate on staff sickness absence is the cost of injuries through manual handling which accounts for 40% of NHS sickness absence costs or in the region of £400 million a year. One in four nurses has taken some time off work with a back injury sustained at work and for some it has meant the end of their careers. Manual handling issues is one of the biggest, most serious issues for NHS staff because of the amount of lifting that is done. The availability of cost information on back pain is one reason why the Department have been able to give it priority, tackle it and as a result see a reduction.[16]

14. Needlestick injury is one area where attempts have been made to quantify the cost-benefits of interventions to reduce accidents through the introduction of safer needles. Such injuries occur mostly to nurses, doctors and ancillary staff. Over a third of nurses and half of agency nurses have been stuck by a needle/sharp at some point in their career, with 7% being stuck more than once in the last 12 months. The Department explained that staff needed to receive improved training, particularly in disposal. A reduction in needlestick injuries also depends on proper surveillance and reporting procedures; a range of preventative measures and safer working practices; and the adoption of safer needles in higher risk areas. We asked the Department for reassurance that this was being dealt with properly.[17]

15. The Department told us that there were 23,000 needlestick injuries reported in 2001-02 compared with 250 million such devices used. The General Accounting Office has produced an evaluation of needlestick injuries which suggested that as many as 25% of accidents reported in the United States of America were potentially preventable because needle use was unnecessary. Therefore this type of accident might also be reduced by confining the use of needles to procedures where there is no alternative.[18]

16. Further evidence, submitted by the Safer Needles Network, also drew attention to the risk of healthcare workers becoming infected following a needlestick injury. Health Protection Agency data shows that in the UK there have been five healthcare workers who acquired HIV occupationally, four of whom are now deceased, and a further 12 healthcare workers who have probably acquired HIV occupationally. The Department said that they were unaware of any cases where HIV had been transmitted through needlestick injuries in this country and that the five cases we raised with them had occurred overseas. The Department has subsequently accepted that these cases happened in UK hospitals.[19]

17. In relation to the costs of needlesticks injuries to the NHS, we noted that UNISON had negotiated a deal with employers whereby claims against NHS trusts for certain needlestick injuries are immediately settled by the trust £2,000. The Department explained that the amount of the compensation had emerged through a series of case studies where there had been a demonstrable case of mental stress. It was not an automatic payment, and employers needed to balance the cost of settling with that of being taken to an employment tribunal and the attendant legal costs.[20]

Compensation and ill health retirement

18. Accidents can result in compensation costs arising from litigation, as evidenced by the examples given in the National Audit Office's Report (reproduced below as Figure 2). In order to help people to manage these costs, they had brought staff accidents into the remit of the NHS Litigation Authority and their risk pooling arrangements, which resemble those through which clinical negligence is handled.[21]Figure 2: Compensation payments awarded by the courts to employees injured in the course of their duties

  • In 1998, a health authority paid an out of court settlement of £465,000 to a junior doctor who developed a psychiatric illness following a sharps injury, even thought the incident did not lead to any physical infection.
  • In 2000, an occupational therapy assistant won £600,000 in compensation for injuries sustained at work. In March 1990 she slipped on a wet vinyl floor fracturing her right ankle. She continued to suffer considerable pain and disability in the knee and ankle, requiring numerous operations, and her employment was terminated on ill health grounds in 1992. In May 1997, she had to have her right leg amputated below the knee.
  • In February 2000, a former intensive care nurse accepted £800,000 compensation in an out of court settlement after injuring his back at work. The incident happened in 1992, when the nurse lifted a patient with just one other colleague, although the NHS Trust policy recommended that staff should use a hoist or a minimum of four members of staff should lift a patient. The award was made on two counts: the lack of a mechanical hoist and that the hospital was deemed to have given inadequate lifting training.
  • In June 2001, a former staff nurse was awarded £347,000 for a back injury caused by repetitive strain while working in a hospital which allegedly lacked suitable equipment to help move patients. She had suffered back pain from 1994 and was retired from Queen's Medical Centre, Nottingham, in 1996.
  • In October 2001, a nurse who had a mental breakdown because of stress and overwork, in the aftermath of a traumatic pregnancy, won £140,000 compensation. The NHS Trust was ruled to have grossly dishonoured the arrangement that had been made to protect her health and welfare upon her return to work and the trust should have foreseen the substantial risk that she would suffer psychiatric injury. Excessive hours, lack of administrative assistance and covering for absent or sick colleagues were contributory. She has retired on the grounds of ill health.
  • In 2002, a healthcare worker received an award of £58,000 for a needlestick injury received in 1997. While assisting a consultant anaesthetist a Senior Operating Departmental Assistant was injured when a tray of needles flipped over. One stuck in his arm, and in attempting to shake it off it penetrated his toe, through his shoe. The needle was contaminated and the assistant suffered severe shock and trauma.
  • In October 2002, the High Court awarded £420,000 compensation for a nurse who was forced to retire in 1998 after moving patients without adequate arrangements. Patients of up to 12 stone in weight had to be manually lifted because the mechanical hoist was shared with another ward and staffing levels were poor. Newham Healthcare NHS Trust also faces legal expenses of £400,000.

Source: National Audit Office Report[22]

19. However, the Department did not think that there was significant abuse of ill health retirement on the grounds of a work-related accident as they had a very sophisticated system of checking and a great deal of occupational health expertise available to them. In addition, the NHS Pensions Agency had conducted a review two to three years ago which resulted in revised guidance for trusts on the handling of cases of this nature. The number of ill health retirements in 2001-02 was 4,507 which is already below the Treasury's target of 3.96 per 1,000 employees by 2005. The Department consider that their guidance "Managing ill health retirement in the NHS: guide for human resource and occupational health service", which was published in November 2001, has tackled any possible incentive to retire early on ill health grounds.[23]

2   2nd Report from the Committee of Public Accounts, Health and Safety in NHS Acute Hospital Trusts in England (HC 350, Session 1997-98) Back

3   C&AG's Report, A Safer Place to Work: Improving the management of health and safety risks to staff in NHS Trusts (HC 623, Session 2002-03) para 1.10 Back

4   ibid, paras 1.11-1.12 and Appendix 2 Back

5   Q1; 39th Report from the Committee of Public Accounts, A Safer Place to Work: Protecting NHS Hospital and Ambulance Staff from Violence and Aggression (HC 527, Session 2002-03) Back

6   C&AG's Report, para 2.8 Back

7   ibid, Figure 4 and Appendix 3, Table 1 Back

8   C&AG's Report, paras 11, 2.9-2.14 and Figures 5a-5c and Figure 6 Back

9   Qq 2-3, 41, 165 Back

10   C&AG's Report, pp 18-25, Appendix 3 para 6 and Table 1; Qq 2-3, 35, 47 Back

11   C&AG's Report, para 2.8; Qq 126-133  Back

12   C&AG's Report, paras 2.2-2.7, Appendix 3; Qq 36-37,41-45, 86 Back

13   Qq 25-33, 37-40, 46 Back

14   C&AG's Report, paras 2.22-2.26 and Figure 11; Qq 166-168, 209 Back

15   Qq 5, 34-35, 166-167 Back

16   C&AG's Report, para 2.24; Appendix 3 (para 6); Qq 3, 35, 47 Back

17   C&AG's Report, pp 20-21, para 2.28 and case example 6; Q 199; Ev 25-26 Back

18   Qq 199, 207 Back

19   Q 208; Ev 23-25 Back

20   C&AG's Report p20; Qq 199-206 Back

21   C&AG's Report, para 2.23 and Figure 10; Qq 6, 7, 75 Back

22   C&AG's Report, Figures 7, 10 Back

23   Qq 136-138; Ev 23 (ref to Qq 137-138) Back

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