Examination of Witnesses (Questions 280-299)
5 MAY 2004
MR KEITH
JOHNSTON, MR
JULIAN TOPPING,
DR GILL
MORGAN, MR
STEVEN SUMNER
AND MR
ROY BENJAMIN
Q280 Chairman: In the final session this
morning, we have with us Keith Johnston, a policy adviser at the
NHS Confederation, Mr Julian Topping, who is occupational health
and safety lead with the NHS and the chief executive, Dr Gill
Morgan. In addition, we have Steven Sumner, who is a national
health and safety policy adviser for the Employers' Organisation
and Roy Benjamin who is the chairman of the National Association
for Safety and Health in Care Services. Ladies and gentlemen,
thank you very much for coming. Thank you very much for the written
submissions which are valuable. Could I ask you both in opening
to set the scene about resources? Obviously a key part of this
inquiry is whether central government and the HSE/HSC is in a
position to be able to deal with what is facing them in the modern
day workplace in terms of the resources available. If you have
some preliminary thoughts about that, that would be helpful.
Dr Morgan: I want to set that
context within the NHS because the NHS is a vastly inspected and
regulated organisation. We have large numbers of inspectors who
come and look at different aspects of care. The aspiration of
employers in the NHS is to see far more of the routine inspection
work done simply and in a collegiate way between the different
inspectors. That would free up more opportunity for organisations
who have much more of an enforcement role to put more of their
resources on the enforcement and less on the prevention side.
One of the things we are very heartened about which I think is
a partial answer to the resources question, which at the moment
we would feel is inadequate, is a lot of work that is going on
between the HSE and the other inspectors; and in particular, the
Health Care Commission, to look at how the vast range of organisations
that go into NHS trusts share the data collection. Even if you
do not have all the resources you need in one individual organisation,
if you look at all the inspectors, there are an awful lot of visits
and times when this sort of information could be picked up. Increasingly,
there is shared data collection to begin to handle some of the
issues. I think the view from the NHS is that if you put that
side together that will begin to provide sufficient resources
round some of the routine inspection but overall the Health and
Safety Executive is under invested in its ability to work alongside
and support the NHS in the work it has to do.
Mr Sumner: Perhaps I can set the
scene in terms of how we intend to deal with issues. I will give
the national policy view and Roy can give the sharp end view of
his experience in dealing with these issues within the social
services departments. We have referred to resources in our written
evidence and I think generally we feel that the HSE are under-resourced,
particularly in the area of field inspectors and EMAS, the Employment
Medical Advisory Service. This is particularly crucial at the
moment as the HSE are currently in the process of changing emphasis
more from safety into health issues. In those terms, we feel that
the health part of the Health and Safety Executive really should
be boosted. In terms of getting the best return on your investment,
the HSE over the past few years has developed its priority programmes,
where it is putting its inspection resource into those areas which
it considers are causing the greatest problems. For local authorities
this means stress, musculoskeletal injuries and things of that
nature which you have asked about in earlier evidence.
Mr Benjamin: From the sharp end,
in trying to deliver good health and safety practices within the
local authority, my experience on a personal level has been that
the HSE involvement has been very positive. I realise that this
may alter from one area to another but our involvement has been
very positive and they seem to have a very clear understanding
of the difficulties associated with delivering good quality care.
One aspect that has crept in slightly more recently is a change
in ethos within the HSE, where instead of having inspectors who
will look at a particular area like the public sector, they will
now look at an area geographically and will look at a variety
of different workplaces. The current position is that we do not
experience any difficulties with the current inspectors. They
seem to be very understanding that we are trying to produce care,
not produce widgets. My fear is—and I think the fear of
a number of colleagues is—that in certain areas this might
not be the case. It is a completely different concept trying to
deliver good health and safety practice when you are dealing with
human beings, as opposed to bricks or nuts and bolts. That is
one of the main areas of concern in terms of HSE involvement.
Q281 Rob Marris: I should declare an
interest as I have earlier. My constituency party receives money
from Thompsons trade union solicitors, who do a lot of health
and safety work. I do not know if you heard the evidence from
the Royal College of Nursing and UNISON earlier on, but it will
refer across the frame to what you were talking about, Dr Morgan,
in terms of shared data collection and so on. What came through
on both sides there in terms of UNISON addressing the social care
sector and the RCN and the NHS is the fragmentation of bodies
involved in health and safety in their sectors. They were putting
forward broadly some kind of model of advisory and research bodies
and then the HSE doing the enforcement side of things. Is that
a model which you think would work?
Dr Morgan: I think it is more
complicated than that.
Q282 Rob Marris: I was simplifying what
they said, to be fair to them.
Dr Morgan: If you look at the
vast number of regulatory and inspection bodies that look at the
NHS, they all have a very sensible rationale behind them and they
all have defined purposes. Some focus on the safety of patients;
some are about staff; some are about how clinical services get
run at a local level; some are about management processes; some
are about how clinical staff engage. Each of them has elements
that very few other people could do. What we are pushing is: let's
recognise that all the different bodies have some value and something
to contribute but, at the core of it, there are certain things
that you could be looking at and collecting once. In the Health
Bill that went through last year, the new Health Care Commission,
the Commission for Health, Audit and Inspection, has been given
a statutory duty to coordinate the work of the inspectors. There
is currently a group meeting to develop a concordat about how
the inspectors will work. They are actively looking at how to
share the things that could be done once; how to use the common
definition of what you are looking at? How do you begin to put
that together in a way which uses the resource from the inspector
side much more sensibly? I think that is coming on and the NHS
Confederation has observer status on that group. What I think
is more difficult and very important in this is the question about
why do some of the recommendations that sometimes come out systematically
and repeatedly from inspectors not get implemented at a local
level. I think part of the issue for the NHS is that if you have
maybe ten inspectors visiting you in a year each of them is going
to come up with 20 recommendations for what you might do. You
begin to multiply at a local level all the things that have to
be delivered and organisations need to take priority. As part
of the work that is going on under the Health Care Commission,
there is going to be a strand of work which looks at how do we
more effectively, at a local level, link up all the actions and
get the inspectors to agree amongst themselves, with the organisation
inspected, what are the ones that will make the biggest difference
and gain, both for patient safety and for staff safety. If we
can do that, we can close the loop and make sure we deliver the
things which will make the biggest impact. At the moment, some
of those get lost because the inspectors have different levels
of power. The HSE has the enforcement power so its recommendations,
if it is going to use enforcement, tend to be put into action,
but a lot of the probably more fundamental recommendations in
terms of changing the culture are often given lesser priority
because there are just so many things that have to be delivered
at a local level.
Q283 Rob Marris: When you sketch it out
like that, it sounds to me very complicated and, to put a value
judgment on it, it sounds overly complicated. A cynic might say
that it is a gravy train for health and safety experts who are
whizzing reports back and forth to each other, co-ordinating here,
there and everywhere but nothing happens on the ground.
Dr Morgan: No. I think the Health
and Safety Executive with its very specific issues is one of the
least complained-about organisations. There are large numbers
of other inspectorates that come to NHS organisations which are
the ones where we would be particularly concerned about what they
do, but the HSE is seen at the acceptable end, the end that tries
to help and works alongside organisations to help produce solutions.
Rob Marris: I was not referring to the
HSE. I was referring to all these others that seem to be floating
around.
Q284 Chairman: Everything is relative.
Dr Morgan: We would not disagree
with you.
Q285 Rob Marris: What about in the local
authority sector?
Mr Sumner: In terms of delivering
care in the local authority sector, health and safety enforcement
is not fragmented to the same extent as I think it would be in
the NHS but certainly it is split. In terms of the voluntary and
private sector, those organisations are inspected by local authority
inspectors, environmental health officers and trained technical
officers. All local authority activities are inspected by the
Health and Safety Executive. There are further issues where the
main activity is nursing. Again, that activity would be inspected
by the Health and Safety Executive, even if it is in the private
or public sector. On top of that of course we have the new Commission,
the Commission for Social Care Inspection, which came into being
earlier on this year. The HSE and local authorities will be involved
in drawing up a memorandum of understanding so that everybody
knows the boundaries of their powers within this framework.
Q286 Rob Marris: Do you think it is going
to work?
Mr Sumner: It has worked for some
time in as much as these divisions have existed for many years
under the enforcing authority regulations. What happens is that
local authorities and the Health and Safety Executive locally
work very closely together and liaise to make sure that those
blurred areas of enforcement are clarified at local level. Hopefully,
inspection is carried out to the appropriate level in the places
where those people have enforcement responsibility.
Q287 Rob Marris: Some politicians keep
banging on about red tape, but it is never clear what they want
to get rid of. Some politicians keep banging on about simplification
and, to some extent, I plead guilty to the latter. I am not sure
what I mean by that in your sector and whether you need it.
Mr Sumner: It seems to have worked
in the past, although the Health and Safety Executive and local
authorities currently are reviewing all enforcement arrangements.
I do not think there are any sacred cows in there in terms of
what might be up for grabs in that reorganisation of enforcement
responsibilities. To some extent, that is outwith my responsibility.
It would be the LGA ( Local Government Association) who would
need to comment on that.
Q288 Rob Marris: Dr Morgan, in terms
of the Health Services Advisory Committee which the RCN tells
us has not met for over a year, do you think that is a good thing
or a bad thing?
Dr Morgan: The committee met on
27 February. It is an HSE committee and it had spent the preceding
nine or ten months reviewing its action because it was not functioning
very well. It has been looking at its constitution and how to
make it a more effective organisation. It met in its new guise
for the first time on 27 February.
Q289 Rob Marris: If we all got by for
nine months or more without it, do we need it or is that a simplification
that we could aspire to?
Dr Morgan: I think it is really
important. The problem with the group was that it was set up in
a confrontational manner in that all the parties sitting at the
table did not share the problem. There were union representatives
and the Department of Health would come along and be shouted at
about what needed to be done. It has been reconstituted to say
that this is everybody's problem; everybody has a stake in delivering
good Health and Safety and we have to do this in a way where we
work more collegiately to find solutions rather than stereotype
about whose fault a particular problem is. We are very committed
to see that. When we take over the employer responsibility from
the department, we would want to be represented in that body.
Q290 Mr Dismore: Can I ask some questions
about stress? Do you think you know enough about the extent and
causes of stress in the NHS?
Mr Topping: Probably not, as most
of the medical profession are polarised on this issue anyway.
There are two opinions. One is that what is today's stress, 20
years ago was quite acceptable. It is just that we are all weak
and lily-livered these days and we expect not to have to do as
much.
Q291 Mr Dismore: 30 years ago people
were happy to work with asbestos.
Mr Topping: Exactly. It is difficult,
as lay people, to get a grip on it when there is so much disagreement
in the medical profession itself. That does not mean that we do
not have to deal with it. The areas around which people are agreed
as far as organisational stress is concerned are things like the
ability to have a decent work/life balance, have some control
over how you work, decent child care facilities, those sorts of
issues which the Department of Health and the NHS have addressed
through the Improving Working Lives Strategy. It is a long term
strategy that will not see everybody coming in, smiling brightly
and feeling totally unstressed straight away. There is an awful
lot of work going on around researching precisely the underlying
causes even more than we have already done but again that is still
on its way. I suppose the basic answer is no, we do not know enough.
We are dealing with those issues that we do know about and some
people are dealing in a better way than others. The HSE has put
out some extremely useful guidance on how they believe it should
be dealt with which has been picked up very well by people across
the NHS, particularly in the wake of their issuing an improvement
notice in Dorset. That gave it the boost that it needed. We have
a long way to go and it is an extremely stressful industry that
we are talking about. The issue is being addressed.
Dr Morgan: I think there are some
really big changes that have happened in the NHS, if you go back.
When I trained 20 odd years ago, if I went onto a ward at night
I maybe had one or two patients on a ward with a drip. We tend
to still have the same level of staffing, but the last time I
went on a ward there were 22 out of 24 patients on a drip. Those
patients therefore are iller, older and have less chance of cure.
That multiplies the stress for individuals because you are working
very hard. You are also working with very vulnerable patients
and I think that has an emotional impact on people. Without doubt,
the changes are significant. The other fact we do know from some
of the survey work that has gone on is that the characters of
managers and how you perceive your manager as an individual makes
a big impact to your work. One of the things that we now do regularly—the
first survey was reported recently—is ask the staff about
how they feel about their organisation and their managers, to
make sure that we are beginning to track what the level of pressure
is. That shows that overall the NHS does very well in terms of
its management but it is quite different from organisation to
organisation. If you are an acute trust, staff tend to have a
lot of confidence in their management but if at the other end
you are in an ambulance trust there is a lot of discomfort. That
is probably one of the factors that is reflected in the differential
sickness rates between organisations. We are doing some work on
that.
Q292 Mr Dismore: The National Audit Office
said that very few NHS trusts were prioritising action on stress.
Is that being dealt with?
Dr Morgan: As part of the Improving
Working Lives initiative, people are looking at these things at
a local level, but the problem is that many of the solutions are
quite difficult. If the core of this, particularly for clinical
staff, is the nature of the patients on the ward it is very difficult
to change the nature of the patients on the ward. People are looking
at other things such as how do you deal with the work/life balance;
how do you give more people support? How do you provide confidential
counselling? We have yet to prove that those things get to the
heart of the matter because if you are dealing with very sick
people under very stressful conditions on a ward it is very difficult
to do that. We are investing in a lot of extra staff and it is
one of those things about seeing no gains in productivity that
everybody is very keen about in the press. One of the reasons
some of the gains are not being seen in hospital productivity
is that extra staff are being employed to work in wards to try
and reduce this pressure at night. That will not translate into
anything where you can say, "This is what we have",
but we very strongly feel that is a quality benefit not only for
patients but particularly for the staff who work in those wards.
We need some measure that reflects that sort of investment.
Q293 Mr Dismore: You mentioned earlier
the HSE improvement notice. Do you think the HSE should be taking
more enforcement action?
Dr Morgan: Our view would be that
enforcement action is a failure because what the NHS should be
doing is working to make sure it never needs another enforcement
action. When it happens, it is a salutary reflection on all our
systems and processes. The answer to that has to be no, but it
has to be no because we are doing better, not because there is
not the opportunity to do it.
Q294 Mr Dismore: Do you think there is
anything stopping the HSE from doing it?
Dr Morgan: No, I do not think
so. I think they are fairly robust when they see problems but
what they try and do is to work with local managers to find a
solution. If you can find a solution and get an even greater gain
because you now put health and safety at the top of the priorities,
that is a much more strategic way of handling it in terms of long
term change than a quick enforcement notice. They do use them
whenever they feel they are not going to get that type of gain.
They are robust.
Q295 Mr Dismore: I understand that the
NAO tells us that the biggest single cause of absence in social
services departments is stress. Again, what are you doing about
it?
Mr Sumner: The data we have indicates
that social services departments have around about the same amount
of stress as the wider local authority employed community. It
is a problem across all local authorities. There is a number of
activities going on in a lot of local authorities in relation
to stress and the HSE has made it a priority programme so local
authorities know that they are going to be asked about stress
when they are visited. In addition to that, the Health and Safety
Executive has embarked on a rolling programme of auditing of local
authorities for their stress management techniques, practices
and procedures. The HSE is certainly concentrating its mind on
stress and therefore local authorities are concentrating their
minds on stress. The indications we have from a limited survey
that we did are that there is a lot of activity going on in the
area of stress locally, within local authorities. So far, in terms
of impact upon the amount of absence caused by stress, bearing
in mind the data we have, it does not indicate that all that stress
absence is due to work related stress. Clearly, there are interactions
between stress levels which may be outside work and in work. Having
said that, employers do not want to see their staff going off
ill and, if they are off ill, they want to get them back quickly.
We have examples of a local authority that was suffering from
an average sickness absence rate of about 16 days a year. They
introduced a prompt intervention on stress related absence within
a framework of managing absence policy, and they reduced their
sickness absence from 16 to 11.5 days within 18 months. There
is a lot of activity going on out there in terms of local authorities.
We just have to see this pay off in the future.
Mr Benjamin: I think the HSE guidance
on advice on management of stress has been very effective in terms
of organisational stress. The difficulty always comes with this
interaction between what goes on outside of the workplace in leisure
and home pursuits and what goes on at work. It is quite interesting
that the two main problem areas that we have in terms of causation
are things like stress, particularly back pain and musculoskeletal
disorders. They are the two areas which are heavily influenced
by what goes on in home and leisure life. We undertake activities
that will cause difficulty with the back right from the time we
start to work. We also all suffer from difficulties with stress
and they have to impact in the workplace, unfortunately.
Q296 David Hamilton: I look at stress
in many ways. We have talked about stress as regards pressure
at work. Is there a difference between the public sector stress
levels and how they are measured compared to within the private
sector where in many cases there are lower wages and longer hours?
Is that measured in the same way across the board and therefore
are you treating like with like?
Mr Sumner: I am afraid I do not
have the data.[1]
Q297 David Hamilton: Is that not available?
Mr Sumner: I am not saying it
is not available. I do not understand at the moment what is going
on in the private sector. The data we have is collected by ill
health absence surveys so this effectively if somebody goes off
work, submits a sick note or rings in with stress. That is the
data we collect from local authorities.
Dr Morgan: The only piece of work
I know is Professor Michael West at Aston University who has done
quite a lot of work on stress in the public sector but has also
done comparators with the private sector. He would have been using
the same scientific instrument. In that case, it does show that
the health service, because that is the work I have seen, is more
stressed than the private sector, using the same instrument.
Q298 Miss Begg: I do not know if you
heard my questions earlier so I will assume you have not. I pointed
out that back pain has been a significant problem for staff in
health and social care sectors. The National Audit Office identified
it as a significant problem in 1996. We are eight years on from
there and the most recent evidence would suggest that the problem
has become worse, even though both UNISON and the Royal College
said that there has been the introduction of a greater use of
good practice and better training, although not enough, in manual
handling techniques. Why is it that, despite all of that, the
problem of back pain seems to be getting worse amongst employers
and what do we need to do to tackle it?
Mr Topping: As far as the NHS
is concerned, because we are people dealing with people, there
has been a huge increase in the amount of technology that is available
but in my own experience there is often a reluctance to use it
because if a patient complains the nurse does not want to use
it. Again, somebody referred earlier to over-caution. Because
nurses are in the profession because they are like they are, there
is certainly still a feeling, no matter how much we try and train
them out of it, that it is always best to try and lift people
because the machinery is not as comfortable as being lifted. The
opposite end of that is, "We are never going to lift anybody
because we have to be safe." It is a very complicated area,
an area in which we have tried desperately to get people not only
trained but retrained and continually retrained, because it is
one of those areas where people always go back to the old habits
that they should have been trained out of, I am afraid.
Dr Morgan: The other thing is
going back to my change in the dependency of patients. You have
iller, sicker patients and patients are not like lifting a sack.
Patients interact with the lift and therefore it is much more
difficult. If you take things like the ambulance service, where
you have increasing levels of hostility, aggression, alcohol,
a whole set of things, it makes the people who get lifted much
more difficult than when you do it within a training environment.
Those changes have a major impact on what we are saying. There
is this big issue that I think is a real challenge about this
balance between the dependence and independence of the individual
patient and the safety of staff. We are almost going from one
end to the other, sometimes getting it unsafe for staff to maximise
the independence of the individual. At other times, we are going
to the other extreme where we are taking away independence so
that we protect staff. It is that judgment, which is a human judgment,
about where is the balance round that individual which is very
difficult to do anything about in training because it is beyond
training. Some of it is about philosophy, belief, culture, the
sort of thing Bill McClimont was talking about. What are we trying
to do with this individual? Those are hard to deal with.
Mr Benjamin: My experience is
certainly not the experience in the reports you have just mentioned.
I work for the largest metropolitan local authority in the country
and certainly back difficulties and manual handling associated
injuries were an enormous problem prior to the manual handling
regulations coming into force. In the 11 years since they have
come into force, by the use of a combination of training and appreciation
and understanding of the need to ensure people's dignity and choice,
but also by introducing the right sort of equipment at the right
time, we have been able to reduce accidents of a manual handling
nature, particularly back injuries, by 65.5% and indeed 70% in
terms of reportable injuries.
Q299 Miss Begg: It is obviously still
an issue in the health sector. The emphasis perhaps has been on
training and on using new equipment to help move people, not on
making sure that the individual, the employee, has been given
the physiotherapy ahead of time. We give them physiotherapy once
they have a problem to rehabilitate them but we do not think of
giving them physiotherapy in the first place as a preventative
measure. For someone who knows they are going to be doing a lifting
job, as most care workers will be at some point, in the role of
employers for good health for staff, I think you should be offering
them that kind of physiotherapy and health care to make sure that
their backs are strengthened, that they are doing the exercises
they need before they are even put into that situation. Then they
would be a lot more confident. They are not going to be over-cautious
and they are not going to damage their back by getting themselves
into a problem that they feel they cannot cope with.
Mr Topping: Interestingly, there
is some work going on both in the west country and in the Midlands
around getting staff fitter because staff these days do seem to
be not as fit as they used to be; and also around rehabilitation
immediately after in case there are problems. We do not have the
results of that yet.
1 Note by witness: Please see written memorandum
2 Paragraph 3.7. The Bristol study indicates that 20% of employees
report as either very or extremely stressed by their work. Back
| 
