Occupational Health : Safer People Handling
Preventing back pain and injury in the health and care sectors
A report of the ‘People Handling Summit’ convened by RoSPA on 20 October 2000 and background papers
Preface by Sir Frank Davies CBE OstJ
Few people realise that back pain causes more hours of suffering than all other causes put together. Of course, some pains are more intense - but they are usually of shorter duration. The problem with back pain is that though the pain from an injured back can be eased, it can rarely be cured. So, regrettably, back pain is for life.
If these simple facts were better known, more individuals would take far better care of their backs.
Musculoskeletal strain or injury accounts for more days off work than all other causes put together. At least 120 million such days - and many more hours - are lost every year because of it. About one third of all accidents reported to the Health & Safety Executive involve manual handling. In some industries, such as health care, this figure is one half. Increasingly, civil actions taken against employers on subject, result in large awards being made to the sufferers.
If employers, in large and small enterprises, understood this then they would treat the subject far more seriously.
Why do people in general (who pay with life long pain) and employers (who pay with hard earned cash) treat the problem in so casual a way? I can only assume it is because the accident or injury lacks the drama of, say, a roof fall or a molten metal spill. Perhaps it is the absence of blood and gore. Or maybe it is because the incident happens to one person at a time and lacks the drama of a multiple accident.
Yet the consequences to the Nation, Industry and individuals are more expensive when taken together and last longer.
This ‘People Handling’ summit is a significant effort to raise awareness of the problem and ways of addressing it.
Sir Frank Davies, CBE, O St J, Chairman, BackCare
People handling summit:
a report of a meeting held at RoSPA on 20 October 2000
Introduction
As well as the personal cost of pain and suffering, back injuries cost UK industry around £5 billion and over 119 million working days every year. Around a third of all accidents reported to the Health and Safety Executive involve manual handling - and in the health care sector, half of all injuries are related to handling loads in the workplace. Indeed, every year 5,000 employees in health and social care work need time off and 4,000 nurses are forced into retirement because of back problems. The majority of such injuries occur when staff in the caring services lift, carry and move patients.
Against this background - and, as its contribution to the European Week of Health and Safety 2000 - the Royal Society for the Prevention of Accidents (RoSPA) convened a People Handling Summit . It was held on 20 October 2000 at the Society’s Birmingham headquarters and was attended by an invited group of leading experts and key representatives of those services whose staff have to help lift and move those in their care. (See Appendix A: Attendance list). A background paper had been circulated prior to the event. (See Appendix B).
Roger Bibbings, RoSPA’s occupational Safety Adviser, explained that the aim of the meeting was to assess current policy and practice, identify best practice, stimulate new initiatives, draw together those points where there was clear consensus - and publicise the results.
The event was chaired by Sir Frank Davies, Chairman of BackCare National Back Pain and a past Chairman of the Health and Safety Commission. The meeting took the form of expert presentations interspersed with general discussion about current practice and problems and what steps should be taken to remedy this major problem.
Chairman’s introduction: Sir Frank Davies
In welcoming all those present, Sir Frank said starkly that there was no cure for a damaged back and yet we had consistently failed to get that simple message across. He was sure that, if people knew and truly understood this crucial fact, they would take better care of themselves and each other. This applies equally to employers: the civil claims taken against employers by those whose backs are injured during the course of their work are getting ever more expensive. Why, then, do employers not take their responsibilities in this matter seriously?
One reason for this lack of response might be that back injuries are perceived as being less dramatic and somehow less serious than other types of injury. This might also be the view of many GPs who, he said, in any event, often gave wrong - and even harmful - advice (probably because they did not keep in touch with new ways of thinking and were often simply out of date).
It was, therefore, vital - set against the alarming number of back injuries with their resulting pain and number of working days lost right across Europe - that basic preventative and prophylactic messages are got across to employers, employees, and the medical profession.
Sarah Mortimer of the University of Wales College of Medicine spoke of the difficulties encountered at the Cardiff and Vale NHS Trust which has undergone two mergers in 18 months. There were 2.4 manual handling adviser posts to cover the entire workforce of 13,000.
Until recently, training staff in good manual handling practice had generally been perceived to be the best way of preventing back injury. But clearly this has not been successful - as the recent compensation payment of over £800,000 to a back injured nurse has illustrated. It has become increasingly clear that, while training remains important, taking an holistic view of the problem and managing the risk effectively is the way forward. Ways of minimising risk are to ensure that:
- Patients are never lifted manually
- Patients are encouraged to assist in their own transfers
- Equipment and furniture - of which there is a great deal on the market - is thoroughly evaluated for the tasks it is expected to perform before purchase.
However, even when good and appropriate equipment is available (which is not necessarily the rule since budgets are low and equipment is often expected to be used inappropriately), there are huge difficulties with pre-existing space restrictions (many hospitals are of Victorian origin); poor design of buildings generally; inaccessible bathrooms and lavatories; lack of adequate training facilities. There are general difficulties with releasing enough staff time to allow training to take place - and, in any event, the workforce is demoralised, making it difficult to motivate them.
Moreover, there is no ‘right’ model to follow: best practice handling techniques seem to change constantly and there are differences between those used by hospital workers and social service/ambulance staff and other care workers.
Ms Mortimer said that solutions were many and varied - but that a good place to start was with sound ergonomics (although it was difficult to actually prove the efficacy of this to senior management). She cited a two year research project undertaken by Nottinghamshire NHS Trust which has 4,700 staff. The researchers looked at each task in relation to space available, building design and equipment. Staff were asked to test equipment before purchase and teams of risk assessment trainers (known as ‘rats’) ensured that staff were kept fully informed throughout.
In this case, the work was fully audited and was shown to have substantially reduced sickness absence by the end of the two year period. The major problems were:
- lack of resources
- lack of understanding by senior management
- insufficient focus on risk management
- lack of a common approach to and standardisation of training and techniques.
Another problem highlighted by Ms Mortimer is that, apart from organisations such as the National Back Exchange, the Royal College of Nurses and BackCare, there is no recognised professional forum where good practice can be shared or which can co-ordinate research into the subject. The establishment of such a forum, a change in management attitudes, the standardisation of training across NHS Trusts, benchmarking and the possibly a ‘passport system’ were all on her wish list for the future.
Mark Gough, the Deputy Clinical Governance Manager of the West Midlands Ambulance Service spoke about the work of the 1,000 ambulance staff who provide round the clock response service to emergency calls (mainly road traffic accidents) plus a routine service in which patients are taken by appointment to and from hospital and other health care facilities, between wards etc. Ambulance staff are seven times more likely to be back injured than in any other occupational group - and they usually have to retire before their time. This is an upward trend - and the workload is increasing too.
Mr Gough said that, while other health care workers have adopted ‘no lift’ policies, ambulance workers have to lift their patients. If patients are badly injured, clearly they cannot help themselves. But the biggest problem was that patients and carers/family members alike have expectations that ambulance staff will carry them, even if they are able to move unaided. That is the prevailing culture: indeed if staff refuse to lift a patient, there would be complaints.
It would seem that appropriate equipment is a large part of the answer - but it must be user friendly and it must not pose as many problems as it solves. Ambulance personnel frequently worked in environments which are dangerous and cramped - and the environment changes with each incident. A carry chair (which has wheels) can weigh 35 kg, a weight which, when the patient is added to it and then has to be manoeuvred down and round stairs, for instance, is too great. Other equipment, such as orthopaedic stretchers (or scoop stretchers), is not always stable and does not necessarily allow ease of access - people do not get ill or injured in good, well lit, roomy places!
To ensure that equipment does not add to all the other problems ambulance staff encounter, the West Midlands Service has established an Equipment Review Group in which the staff themselves are involved. The first item it looked at was the stretcher which could be used without the need for manual handling, e.g. easiload /hydraulic lift stretchers. The Americans having been using these for years ( witness many police/hospital dramas of the 70s). Why are we so slow to pick up on such innovations, asked Mr Gough?
Other steps taken by the Review Group had included fitting vehicles with ramps - a low tech solution which works. Ambulance staff use pat slides to transfer patients from stretcher to beds. New carry chairs are under review. Banana boards (especially useful for RTAs), penny discs, pediturn boards are all being brought into use where appropriate. This is all backed by regular equipment maintenance on a planned, rolling programme.
The second measure which has been taken has been to introduce more comprehensive staff induction including back care sessions. These have been very well received. Fitness programmes for the staff have been introduced as has fitness testing both for existing and potential employees (to ensure that they are suitable for the job).
The third element is that there is now an efficient reporting mechanism for back pain and injury so that evidence of the scale of problem can be gathered.
And lastly self risk assessment is becoming a reality which means that patients who can move themselves are being asked to do so as long as it can be done safely.
Frank Ursell is the Chief Executive Officer of the Registered Nursing Home Association and an employer representative on the Health Service Advisory Committee. He explained that there are 6,000 Registered Nursing Homes in the voluntary sector in the UK, providing private, 24 hour nursing care. The role of the Association is to support its members.
Just as in the NHS and the ambulance service, there is a huge problem of back injury in his field too. Most of the patients are extremely dependant on the staff moving them since they are, generally speaking, older people in receipt of long term care, many of whom have special needs. The very fact that they have become residents means that they probably underwent emotional trauma at having to leave their own homes so it is essential to provide them with as homely an environment as possible and to treat them with respect.
But this does mean that staff need to understand how to minimise the risk to their backs. In Mr. Ursell’s view it is folly for owners of nursing homes not to invest in appropriate handling aids. The assessment of care workers’ health and safety must be go hand in hand with patients’ needs. If this did not happen and injuries occur, the workers would not be available for work (with all that means for additional recruitment and training costs) and personal injury claims can be very high.
However, Mr Ursell warned that there was a tension between protecting staff and preserving the independence and dignity of patients - for instance, some residents find hoists dehumanising. He also pointed to the need for ‘joined up thinking’ between the various caring agencies, not only in training and selection of equipment but in how the use of handling aids should be negotiated between agencies and clients. He cited the case of an elderly lady suffering from Alzheimer’s disease. She and her husband found the use of a hoist in their own home, as advocated by social services, distressing and cumbersome but when they refused to use it, the local authority withdrew support from them.
Margaret Hanson of the Institute of Occupational Medicine and a member of the Ergonomics Society explained that, in January 2001, she would be embarking on a research project, just commissioned by HSE, on establishing the principles of good manual handling practice. With its focus on lifting and carrying, she is aiming to identify gaps in the current guidance on manual handling principles and fill them in. The project would not concentrate entirely on people handling but extend to all types of manual handling.
She noted that, at present, guidance centred around training people to use their leg muscles rather than their backs to take the weight of the load; to keep the feet close and adjacent to the load; to lift squarely; and to move in the direction of the load. However, while this is true and is good practice when dealing with inanimate loads, there are many loads - especially those involving people and animals - which make this impossible. The task (one handed lifts, kneeling, having to arch over etc) and the environmental constraints (people trapped in vehicles or in confined spaces with difficult access etc) plus the possible unwillingness or inability of the person concerned conspired to make the lifter disregard training.
Her methodology for the research would be to:
- Consult trainers (both those directly concerned with training workers and those who train trainers) about the current gaps in the guidance;
- Consult with scientific experts to establish good principles;
- Return to the trainers to see if what the experts have suggested actually works in practice and to ensure that any resulting guidance is usable.
- She also made the point that she would take into account other studies - such as that carried out by Sue Hignett at Nottingham University which has video footage of how nurses bend and stretch. There was no point in reinventing the wheel.
- The issues with which she expects to deal are many and varied. For instance:
- There are a huge number of staff in higher risk groups. Apart from the problems thrown up by having to lift patients, carers might have pre-existing ill health conditions such as painful knees and hips or might themselves be getting older. It is therefore essential to think beyond the task to the individual.
- Work pressures and the amount of time available will have a direct bearing on whether training is implemented in the work situation. It often takes longer to perform a task the safe way so perhaps quicker techniques need investigation. For instance, health staff may be trained to adjust bed controls so that the patient is at the right height. But to actually do this twenty times an hour can be perceived as taking too much time.
- The training/classroom environment is totally different from the work situation.
- There is the reality of budgetary constraints which puts pressure on staff.
- The very word ‘care’ gives rise to many emotions: people can feel guilty about putting their own needs for healthy backs before the direct pleas for help from patients and relatives.
- The changing pattern of staffing within the NHS means that there are many short term contracts/self employed contractors. This makes establishing training programmes extremely difficult.
Ms Hanson said she would also investigate how training is currently provided. In her view, risk assessment is the key to the future. Trainers need to move away from the ‘this is how you lift and carry’ approach to ‘’how do you ... cope in such a circumstance?" It is important that those providing the training are qualified to do so and that managers fully understand the principles behind such training. Only in this way would it be possible to get away from the belief that showing employees videos was the same as training them.
Peter Maleczek, a Royal College of Nursing manual handling adviser and elected and accredited trade union safety representative said that his role was to aid the process of consultation and communication, specifically by the formulation of health and safety committees in the workplace.
In his view, accident investigation was imperative. It is important to know, for instance, how many back injuries occur as a result of manual handling, yet such information is not often sought by employers. Often it is not known which grades of staff are involved and the tasks they are carrying out. Roles within the NHS are constantly changing - for instance, nurses might well no longer lift and carry patients but this may now be being carried out by nursing auxiliaries.
Until mechanisms were in place to follow up each occurrence, employers could not learn from their mistakes.
Another important question was that of equipment. Often lifting aids are bought but this is without knowledge of the task it is required to do and with no defined purchasing procedures.
The staff must be involved and the safety rep has a role to play here.
Conclusions
Sir Frank’s summing up of the day was hard hitting and to the point:
National framework
A national framework for dealing with the risk of manual handling injuries in the health and care sectors must be created. This would involve establishing a national reporting scheme to establish the true extent of the problem since current statistics were clearly not accurate. The lead should come from Government since new resources will be required. But the Government machine runs on income and expenditure - not a balance sheet and is, therefore, not geared up to looking at the enormous cost savings that could be achieved if the appropriate investment in healthy backs were made.
Enforcement action
It is a fact that that the health and education sectors have a dreadful record in relation to manual handling injuries: together they account for 50% more such injuries than across industry as a whole. There is a huge shortage of staff which adds to the problem. Yet nothing is being done about it. In Sir Frank’s view, it amounted to gross negligence. Generally speaking, HSE are loathe to take NHS Trusts and educational establishments to court (which is probably a throwback to when Crown Immunity was in place), although this is patchy across the country. Yet enforcement action is a powerful way of sending out the message that change is vital.
Guidance
On the whole, larger organisations try to provide effective manual handling training. But the fact is that half the workforce are employed by small and medium sized enterprises (SMEs) - and these employers simply did not train their employees well, if at all. Any guidance, therefore, had to be written for specialist areas and marketed specifically into the target audience.
Training
Before attempting to train anyone, trainers must take the time and trouble to find out how workers are actually working and get to understand the types of environment in which they were expected to operate whether this be in hospitals, out at the site of road traffic accidents, special schools, in industry etc. The credibility of the trainer was crucial - and was undermined if this did not happen.
Accident investigation
Information about the immediate and underlying causes of back injuries is often simply not collected by employers. And if it is, it will often not provide adequate information about what the person had been doing at the time; whether or not this was the individual’s regular job etc. But all back injuries to staff should be investigated so that the appropriate lessons could be learned by management.
Standardisation of approach/networking
It would appear that all those sectors which involve the carrying, lifting and handling of people (which does not just include nurses, paramedics, social workers, those working with children - but fire fighters, policemen etc) are all using different techniques not only across different sectors but within the same sector but working for different authorities. For instance, only four police services recommend that handcuffs are only used once the subject has stopped struggling. People must talk to each other since only in this way can good practice be spread.
Management commitment
As in all other industries, nothing will happen until the problem of back pain and injury is acknowledged by those in control and they signal that they want things to change.
General comments
Comments from those attending the meeting were made throughout the day and, even though the sectors in which they worked were many and varied, there was general agreement with what each of the speakers had said in terms of the need for:
- standardisation of principles of lifting and handling;
- standardisation of training methods;
- a central point for sharing information and discussion and the establishment of ‘beacon’ sites;
- methods for assessing the relevance and appropriateness of equipment; and
- a drive to alter patients’ and relatives’ expectations of what care workers should be expected to do
Other specific points were:
- the NHS to have an overview of what back pain and injury is costing the service in financial terms and a co-ordinated strategy for preventative action;
- greater rigour in collecting and providing evidence and putting the argument forward to management and government;
- setting local and national achievable targets for back pain/injury reduction and ensuring these are met;
- overturning the ‘blame culture’ which exists in the health services; and
- a debate about whether training exercises should involve putting the trainees at real risk.
RoSPA’s initial conclusions
The current level of injury and economic loss due to people handling injuries in the health and care sectors is totally unacceptable. The true significance and impact of such injury for individuals, their families and organisations is still insufficiently understood.
More work is needed at ground level to highlight: the prevalence of manual handling injuries; what they mean for individual sufferers in particular cases; their economic consequences and their preventability. Cases of manual handling injury which have severely disabling consequences should be regarded as just as serious as other kinds of more clearly visible serious injury due to accidents.
There are clear legal requirements for employers to take action. Clear standards and guidance have been set and numerous training and technologically based solutions have been established. Where employers are manifestly failing to respond to their duties of care, appropriate enforcement action should be taken.
Poor progress in applying established solutions may be a reflection of continuing difficulties in establishing a sufficiently rigorous approach to health and safety management in the health and care sectors.
The National Health Service is under a clear obligation to respond to the Government’s and the Health and Safety Commission’s recommendation in ‘Revitalising Health and Safety at Work’ that all Government Departments and public sector employers should seek to move beyond legal compliance and reach ‘best practice’ in their management of work related risks to employees, contractors and members of the public.
Progress in reducing people handling injuries will be a key indicator of the extent to which the health and care sectors have been able to reach this goal.
Although within the NHS, the ‘Health at Work in the NHS’ (HAWNHS) programme has taken some specific initiatives on behalf of nurses and ambulance workers, this does not appear to represent a sufficiently high level, co-ordinated approach to make prevention of manual handling injuries in the health and care sectors injury due to people handling an over-riding priority. The Department of Health and the NHS Executive clearly have lead roles to play in formulating such a strategic approach. A key element of any such national strategy must be the establishment of evidenced based people handling injury reduction targets in line with the overall headline targets for injury and ill-health reduction set in ‘Revitalising’.
Any new national strategy for reduction of such injury must be underpinned by a clear Cost Benefit Analysis. Further, in setting their own evidence based reduction targets, individual NHS Trusts and other organisations must be encouraged to undertake and publicise their own CBA’s, making use, for example, of the methodology being promoted in the HSE’s ‘Ready Reckoner’, which has been recommended in ‘Revitalising’.
A further element in the strategy might include the establishment of a special ‘People Handling’ website with both signposting and interactive facilities, to raise awareness of innovative approaches and to allow for exchange of information and ideas between ‘key players’, particularly at local level.
A special board, involving a wide variety of ‘key players’ as well as individuals chosen because of their ground level experience, should be established by the DoH under a senior independent chair, to develop and promote the strategy and to monitor and report on progress.
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