Roger Kline, Research Fellow at Middlesex University, highlights the three principles NHS organisations should take forward immediately to avoid unecessary staff deaths.
Well over a hundred NHS staff have died from COVID-19 and we’re not clear why.
COVID-19 disproportionately impacts on some groups of people but we have known for a long time that it was likely to. The NHS nationally failed to ensure (or even ask whether) all employers conducted the statutory risk assessments which should have been carried out weeks ago and which might have prevented some of the tragic staff deaths and illness we have seen.
There are growing signs that the NHS nationally and individual employers are starting to do what should have been done weeks ago. I want to suggest three principles which should inform employers’ approach going forward
1. What employers do can make a substantial difference
When the deaths of 119 NHS staff were analysed by three leading clinicians they found that the proportion of nursing and support staff who died from COVID-19 was three times as high as their proportion in the NHS workforce and for doctors it was twice as high.
But their most remarkable finding seemed to largely slip under the radar.
Anaesthetists, intensive care doctors and by association nurses and physiotherapists who work in similar settings are believed to be among the highest risk groups of all healthcare workers because they care for the sickest patients with COVID-19, undertake airway management and have high risk of viral exposure and transmission.
However the analysis found there were no anaesthetists or other intensive care doctors amongst those who died. They found that of those whose speciality was identified, none were described as intensive care nurses. There were also no deaths of physiotherapists reported. The researchers conclude that
…the reason for this is not known and data on infections and serious illnesses are important to consider as well as fatalities, but this data is also currently lacking. What is likely is that these groups of healthcare staff are rigorous about use of personal protective equipment and the associated practices known to reduce risk (emphasis added).
It may be that this rigour is protecting staff better than some fear and the results can be considered cautiously reassuring. However, this finding is not a reason to slacken off on the appropriately rigorous use of PPE, but rather to wonder why others, who are likely involved in what are generally considered to be lower risk activities, are becoming infected and consider whether wider use of rigorous PPE is indicated.
What implications does this have for NHS employers? The researchers suggest a crucial one
It is not possible to know whether infection occurred at home or at work, but we have determined that the vast majority of individuals who died had both patient-facing jobs and were actively working during the pandemic. It seems likely that, unfortunately, many of the episodes of infection will have occurred during the course of work.
Had the statutory risk assessments been undertaken several weeks ago as they should have been, they would have highlighted the greater risks to some groups of staff and inevitably recommended special attention be paid to eliminating or mitigating those risks.
The risks were:
- Staff from any backgrounds with long term health conditions would be especially vulnerable to a Coronavirus pandemic
- BME staff being amongst those groups especially prone to such long term health conditions
- BME staff being disproportionately represented amongst lower graded front line health and social care staff who might generally be at greater risk
- BME staff have been found to be less likely to raise safety concerns either because they do not believe they are listened to or because they fear the consequences of doing so
- BME being more likely (I’ve not seen robust data on this) to work night shifts where communication and safety measures may be more poorly managed
In addition, there has been significant anecdotal evidence that BME staff believe they are being disproportionately placed on wards with greater COVID-19 risks where staff are reorganised on a temporary basis to cope with the pandemic.
Finally, those dying do not look like those making the decisions. There is a steep ethnicity gradient across the NHS with career progression much harder for BME staff and senior positions generally well out of reach despite some recent limited progress. Diverse teams make better decisions and we don’t have nearly enough diverse senior leadership teams prepared to put themselves in other peoples’ shoes.
At a time when PPE was in serious shortage, these factors contributed to a perfect storm. The results are in the news bulletins every day. The risks were reasonably foreseeable. However, not only were many of these deaths probably avoidable but if the right measures are taken now by NHS employers, the death rate and illness rates amongst all staff but especially BME staff can be radically cut.
For that to happen two other conditions must be met.
2. Employers must take prime responsibility for staff health, safety and well-being
The statutory requirements on health and safety at work of employees, and the statutory requirements in respect of equality are primarily for employers to actively implement rather than for employees to complain when they are breached.
- Section 1 (2) Health and Safety at Work etc Act 1974 states: “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.”
- Regulation 3 (1) of the Management of Health and Safety at Work Regulations 1999 provides that: “Every employer shall make a suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst they are at work; and the risks to the health and safety of persons not in his employment arising out of or in connection with the conduct by him of his undertaking”
- The Personal Protective Equipment at Work Regulations 1992. Regulation 4 (1) provides that “every employer shall ensure that suitable personal protective equipment is provided to his employees who may be exposed to a risk to their health and safety except where and to the extent such a risk has been adequately controlled by other means which are equally or more effective.”
At the same time however, human resources practice has steadily drifted towards a culture where policies, procedures and training are put in place which focus on enabling individuals to safely raise concerns rather than the employer being proactive and preventative. The problem is that such an approach does not work. Research on bullying, for example, concluded that
In sum, while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace, there are significant obstacles to resolution at every stage of the process that such policies typically provide. It is perhaps not surprising, then, that research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces.acas.org.uk
Similarly for equality:
…attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management […] programmes which targeted managerial stereotyping through education and feedback (i.e. diversity training and diversity evaluations) were not followed by increases in diversity.cfa.harvard.eu
There has been a similar approach in respect of staff raising concerns (whistle blowing) where it is still left far too much to individual members of staff to be brave or foolish enough to raise concerns rather than employers proactively intervening to change the organisational climate at work.
The wider industrial relations context over the last three decades has been one that has seen a move away from ‘collective bargaining’, towards one that has relied much more on a floor of employment rights that is overwhelmingly individualist in nature. Even when individuals successfully challenge inappropriate decision making using employer policies and procedures, they often have little impact on the conditions of other workers other than possibly tightening up employer policies, procedures and training, which are designed as much to defend employers as to improve outcomes – impacting on what trade unions can achieve
In respect of COVID-19, therefore, it is crucial that the emphasis is on clear expectations, monitored by both the CQC and NHSi/E, that employers will act decisively to protect all staff and especially those that evidence suggests are most at risk.
This should be done through:
- Urgent risk assessments made public and involving staff and unions
- The provision of suitable and safe PPE
- Enhanced staff testing
- Enhanced data collection and analysis to assist proactive intervention
- Enforcing social distancing and ensuring that staff who can do so work from home subject to service needs
- Actively listening to staff and acting on their concerns and suggestions, and ensuring it is safe to do so
3. The narrative is crucial
All employers have a statutory duty to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all their employees. It is one aspect of the duty of care owed by all employers to their employees, contractors and visitors.
No member of staff should be exposed to risks that are reasonably foreseeable and which can be eliminated or mitigated. We know that some groups of NHS staff are at particular risk, notably those with underlying health conditions. We know that Black and Minority Ethnic staff are amongst those particularly at risk and are disproportionately working on the front line in lower graded roles, subject to more bullying, more reluctant to raise concerns, and may be more likely to work night shifts.
It is therefore especially important that when undertaking and acting on risk assessments Black and Minority Ethnic staff are accorded particular attention because they may be at greater risk, as the death and infection rates from COVID-19 for NHS staff as a whole show.
Failure to do so would be a breach of the employer’s duty of care and would risk unnecessary harm. Let us be clear. This is not an alternative to addressing the risks faced by all staff and ensuring all staff are as safe as possible, but is an integral part of such an approach which recognises that some groups, notably BME staff, are especially at risk.
The initial analysis of NHS staff deaths suggest that where the statutory requirements are fully met, risk is indeed greatly reduced. There is no time to be lost in taking the steps suggested especially as individual trusts and the NHS nationally have now accepted there is much to be done, and at speed.