THE UNITED KINGDOM PARLIAMENT

SECOND REPORT

The Committee of Public Accounts has agreed to the following Report:

HEALTH AND SAFETY IN NHS ACUTE HOSPITAL TRUSTS IN ENGLAND

	INTRODUCTION AND SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS
C&AG's Report (HC 82 of Session 1996-97), para 3	1.  National Health Service organisations are required under the Health and Safety at Work etc Act, 1974 to ensure as far, as reasonably practicable, the health and safety of their patients, visitors and employees. Since the first NHS trusts were established in 1991, they have been subject to the full requirements of health and safety legislation.
C&AG's Report para 2	2.  Good employers actively seek to reduce the risks of accidents at work as they may cause death, injury or ill-health. They may also result in costs, for example in treating injuries, loss of staff time and compensation payments. Poor attention to health and safety issues may have wider detrimental effects too, on the quality of services, staff morale and public opinion on the NHS.
C&AG's Report, paras 17 and 20	3.  In his Report, the Comptroller and Auditor General estimated that, allowing for under recording, there may have been in excess of one million accidents in NHS acute hospital trusts in England in 1995, and that the costs of these accidents were likely to have been at least £154 million a year.
	4.  On the basis of this Report, our predecessors examined the costs and level of accidents in NHS acute hospital trusts, trusts' compliance with legislation and guidance, and responsibilities for monitoring and improving the management of health and safety.
	5.  Our main conclusions and recommendations are as follows:
	The costs and level of accidents in NHS acute hospital trusts
	(i)  We are concerned that hospitals are such dangerous places for patients, staff and visitors; and we note that the large number of accidents imposes a very significant burden on NHS resources which could be better spent on patient care (paragraph 17).
	(ii)  We consider it unsatisfactory that, despite the NHS Executive's previous guidance, many hospitals do not have accident recording systems which provide accurate and timely information. We are also concerned at the very wide differences in accident rates recorded by trusts and the difficulties in making comparisons because of under-reporting (paragraph 18).
	(iii)  We consider it vital that trusts have accurate and up to date information to help them assess health and safety risks, to identify areas where action is needed to reduce these risks, and to minimise the costs involved. We therefore expect all NHS trusts to introduce as a matter of urgency accident recording systems which meet the principles set out in the Comptroller and Auditor General's report (paragraph 18).
	(iv)  We are concerned that some staff may be discouraged from reporting accidents. We look to NHS trusts to take a stronger lead in encouraging their staff to report all accidents promptly (paragraph 19).
	Trusts' compliance with legislation and guidance
	(v)  We are disturbed by the low and variable levels of trusts' compliance with health and safety legislation and that the NHS Executive were unaware of this state of affairs. We consider it highly unsatisfactory that the health sector reports to the Health and Safety Executive only 37 per cent of the accidents which it is legally required to report (paragraph 27).
	(vi)  We note the NHS Executive's view that the position has improved since the removal of Crown immunity, but we consider that there is still a long way to go before the NHS can demonstrate an acceptable level of performance in this area (paragraph 28).
	(vii)  We are concerned that there has been only limited action on the part of trusts in response to the considerable volume of guidance issued in recent years by the NHS Executive. We are also surprised that there has been little effective check on whether trusts are implementing such guidance. We do not regard it as acceptable for the NHS Executive to rely on the Health and Safety Executive on this issue (paragraph 29).
	(viii)  We expect trusts to draw up detailed action plans for achieving full compliance with legislation and that trust boards should regularly review progress against such plans. We also recommend that the NHS Executive should review the progress made by trusts in implementing these arrangements (paragraph 30).
	Responsibilities for monitoring and improving the management of health and safety
	(ix)  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 (paragraph 51).
	(x)  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 (paragraph 51).
	(xi)  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 (paragraph 52).
	(xii)  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 (paragraph 52).
	(xiii)  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 particularly 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 (paragraph 53).
	(xiv)  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 (paragraph 54).
	(xv)  We note the Executive's view that trust boards have not been paying sufficient attention to health and safety issue. 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 (paragraph 55).
	(xvi)  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 (paragraph 56).
	The costs and level of accidents in NHS acute hospital trusts
C&AG's Report, paras 17 and 20	6.  On the basis of an accident recording exercise in 30 trusts, the National Audit Office estimated that there were likely to have been some 450,000 accidents during 1995 in NHS acute hospital trusts in England. Allowing for under recording, there may have been in excess of one million accidents. The costs of accidents were likely to have been at least £154 million a year.
Q 1	7.  Our predecessors suggested to the NHS Executive that this £154 million was money which could have been going into patient care. The NHS Executive agreed that the figures were dramatic but had to be seen in the context of an organisation that employed one million people, and had almost 60 million patients and 100 million visitors passing through its doors every year. In this situation, there would be an irreducible minimum of accidents that were bound to happen.
Qs 24, 26, 28, 123-124	8.  The Executive accepted however that the cost of accidents was money diverted from other things, and agreed that they had an interest in ensuring that people were complying with standards which would diminish that cost. They added that, at local level, the costs were now being felt by the people running the organisations in which accidents happened, and these people therefore had a greater financial incentive than in the past to ensure that the money was spent on patient care.
Q 2	9.  Our predecessors asked the NHS Executive whether the cost of accidents suggested that it was more dangerous to be in a hospital than in most places of work. The Executive said that some very dangerous occupations were carried out in hospitals, and across the whole range of laboratory, X-ray and clinical activity there were a great many hazards to be dealt with. And many people treated in hospital were frail and elderly people. Comparative figures, produced by the Health and Safety Commission, showed that the NHS compared reasonably well against other service industries and against British industry as a whole. However, one difficulty was that figures for the NHS could not be distilled out from the figures for the health and social care sector in the round.
C&AG's Report paras 1.3 and 1.7 para 1.14	10.  Hospital managers need reliable incident recording systems to meet their statutory obligations for reporting serious accidents to the Health and Safety Executive, and to identify risks and areas where action is needed to rectify persistent health and safety problems. Although the NHS Executive issued guidance on incident recording systems in 1993, 17 of the 30 trusts visited by the National Audit Office did not have systems which met the requirements of a good system. The Health and Safety Executive estimated that the health sector report, on average, only 37 per cent of the accidents they are legally required to report.
Qs 18, 49 Qs 51-53 Q 18	11.  Our predecessors asked the NHS Executive what they were doing to ensure that trusts reported all accidents. The Executive said that they had repeated their guidance in 1996. This recommended use of two forms-one for incidents affecting people and another for incidents affecting property. The elements of simplicity and a standard definition of accidents were the right principles to work to. Each of the 30 trusts which took part in the study carried out by the National Audit Office now ran a sensible system in line with the Executive's principles and the tenets set out in the Comptroller and Auditor General's Report. The NHS Executive added that they expected all trusts to have a proper system because it was not that expensive: given the sort of software which was available, costs as low as £20,000 to £25,000 would not be unreasonable. The Executive confirmed that they intended to use the Report as an additional lever to ensure that trusts followed best practice.
Evidence pp 1-3	12.  In their submission to the Committee, UNISON stated that in two surveys they had conducted on violence to health service staff, less than two thirds were encouraged to report incidents and between 15 and 20 per cent were discouraged from doing so. Their survey also showed that around a third of NHS staff were unaware of the reporting procedures. It was also common for UNISON to receive complaints from members that they could not find the accident book or were discouraged from filling it in.
Qs 103-104	13.  The NHS Executive accepted that if someone was operating in an environment which did not have a good system and did not encourage staff to report or made it bureaucratically complex for staff to report, then that was not a good thing.
C&AG's Report, para 1.13 and Figures 3 and 4	14.  Although the numbers of accidents recorded by trusts did vary in relation to their size, there were also considerably wider differences in the accident rates recorded, suggesting different levels of success by trusts in preventing accidents.
Qs 4, 39	15.  Our predecessors asked the NHS Executive why, for example, the rate of patient accidents in one hospital could be nine times the lowest level recorded. The Executive said that they needed to be very clear about the definition of best and worst. They could not necessarily assume that the hospital with the highest accident rates was badly run and the other was not; it might be that the first hospital had a very good recording system, while the one with the lowest accident rates did not.
Qs 41,44	16.  The NHS Executive added that of the hospitals covered by the National Audit Office study, the hospitals with the highest and lowest rates of staff accidents (Royal Liverpool Hospital and South Manchester University Hospital, respectively) were very similar institutions. The reasons for the differences between them were a combination of the physical environment, the reporting systems and the extent to which the board and senior people within the hospital were focused on this issue.
	Conclusions
	17.  We are concerned that hospitals are such dangerous places for patients, staff and visitors; and we note that the large number of accidents imposes a very significant burden on NHS resources which could be better spent on patient care.
	18.  We consider it unsatisfactory that, despite the NHS Executive's previous guidance, many hospitals do not have accident recording systems which provide accurate and timely information. We are also concerned at the very wide differences in accident rates recorded by trusts and the difficulties in making comparisons because of under-reporting. We consider it vital that trusts have accurate and up to date information to help them assess health and safety risks, to identify areas where action is needed to reduce these risks, and to minimise the costs involved. We therefore expect that all NHS trusts to introduce as a matter of urgency accident recording systems which meet the principles set out in the Comptroller and Auditor General's report.
	19.  We are concerned that some staff may be discouraged from reporting accidents. We look to NHS trusts to take a stronger lead in encouraging their staff to report all accidents promptly.