There is much we don’t yet know about COVID 19. But we know enough to do much better in limiting its spread amongst health and social care staff. The number of deaths amongst health and social care workers alone is much higher that the annual average total number of UK workers dying from ALL accidents at work over the last 5 years: 200 compared to 312 and rising. And the rate of COVID deaths are much higher amongst some groups of staff, notably BME staff.
So what can employers do better?
Firstly, make sure individual staff risk assessments are an absolute priority both for health conditions and for their treatment at work.
Statutory risk assessments should have started in late February and been completed by mid-March at the latest. I’ve discussed the widespread breach of the employers’ duty of care elsewhere but even now the quality of risk assessments and their implementation varies between the very serious and the flimsy.
Secondly, understand the crucial importance of occupational exposure as a key driver of COVID 19 infection amongst staff.
Though no single piece of evidence is absolutely conclusive, the evidence is mounting up:
Researchers from Public Health England (PHE) concluded this week that 20% of cases among hospital inpatients and 89% of cases among healthcare workers were down to hospital-acquired infections. They estimated that 21% of coronavirus infections among hospital patients and 89% of infections among healthcare workers may have been caught in hospital, researchers have revealed. . They say this is not surprising due to exposure within hospitals to patients with Covid-19 and long hours spent working in healthcare settings and therefore also fewer hours spent in community settings.” This study is not yet peer reviewed but its broad conclusion seems clear.
Analysis of the deaths of the first 130 NHS staff to die from COVID 19 came to similar conclusions about their causes. They found that no anaesthetists, intensive care doctors, nurses and physiotherapists who care for the sickest patients with Covid 19, and who undertake airway management with high risk of viral exposure and transmission had died. They suggested that this was because these groups of healthcare staff (in ICU) are rigorous about use of personal protective equipment and the associated practices known to reduce risk.
They found that “the vast majority of (NHS staff) 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. ”
They also found that younger female NHS workers (35% of the NHS workforce) may have a mortality rate approximately twice that of their peers who are not NHS staff” whereas it is normally lower.
So serious is the rate of infection amongst health and social care staff compared to the wider population that one epidemiologist summarised one week’s data as follows:
“Half of all new infections reported last week were among healthcare workers. This has now become the leading edge of the spread of the disease.”
There may be some good news however. The latest ONS data suggests employers are finally taking action on staff safety. Their latest survey reports that of those working with patients in healthcare and those in social care roles, the proportion who tested positive for Covid-19 was similar to the rate for those doing other jobs whereas the previous two week survey found people working in patient-facing roles had a much higher rate of infection.
That suggests the pressure to improve staff safety is working. It will need to be sustained.
Thirdly, do not see the disproportionate infection rates and deaths of BME staff as primarily an equality issue rather than a safety issue. It is a safety issue that is also an equality issue.
We know that Covid 19 disproportionately impacts on some groups of people (BME, older men, people with a range of pre-existing health conditions, poorer people and others) though the precise causes are a matter for further research and we have known for a decade that in a future influenza type pandemic Black and Minority Ethnic people in particular were more likely to be affected. We also know that BME staff are disproportionately at risk.
But crucially this is a safety issue. No member of staff (whatever their background) should be exposed to risks that are foreseeable and which can be eliminated or mitigated. But we also know that some groups of NHS staff are at particular risk.
It is therefore right, when undertaking and acting on risk assessments that, Black and Minority Ethnic staff, for example, are accorded particular attention because they may be at greater risk, as the death and infection rates for health and social care staff as a whole show.Failure to do so could be a breach of the employer’s duty of care and would risk unnecessary harm.
Fourthly, accept that crucial to occupational exposure is how some groups of staff (especially BME staff) are treated in their organisations.
The new national NHS Risk Assessment tool is helpful as a basis for developing an effective, easy to use long term health conditions risk assessment but it is does not address the discriminatory treatment faced by BME staff in particular. Yet it is that treatment that helps drive differing levels of infection and death from occupational exposure:
BME staff are disproportionately represented amongst lower graded front line health and social care staff who might generally be at greater risk
BME staff are 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 – and they are more likely to be bullied at work
BME staff may be (I’ve not seen robust data on this) more likely to work night shifts where communication and safety measures may be more poorly managed
There is significant anecdotal evidence that BME staff believe they are being disproportionately deployed onto wards with greater Covid 19 risks where staff are reorganised on a temporary basis to cope with the pandemic.
Diverse teams make better decisions and we don’t have nearly enough diverse senior leadership teams who put themselves in the shoes of those on the front line. Yet thosedying do not look like those making the decisions. So the cumulative impact of these workforce factors exacerbates the inequality arising from long standing health conditions.
Fifthly, as a result, alongside health risk assessments, undertake assessments of how staff are treated (especially BME staff) and act on them. I suggest ten must dos:
Urgently complete individual risk assessments for all staff using a reliable tool.
Depending on the outcomes of those risk assessments (a) ensuring the provision of suitable and safe PPE which has been subjected to a fit test (b) not expecting staff to place their lives in danger if it is not (c) enforcing social distancing and ensuring that staff who can do so work from home subject to service needs (d) making sure staff who are at greater risk from their health assessments either work from home, or in less risky areas (e) making safe arrangement for those who have vulnerable relatives in their house are not expected to work except at home
Step up staff testing. PHE researchers found that “Daily testing was the most effective at reducing transmission with a reduction of 65% in [healthcare worker to healthcare worker transmission events], and 14% in healthcare worker to patient transmission events,”
Actively listen to staff and acting on their concerns and suggestions and ensuring it is safe to do so – recognising that BME staff in particular may be less likely to raise concerns because they believe they will not be listened to or because they fear the consequences of doing so
Pay special attention to agency staff, bank staff, staff returning from sick leave, night shift workers and newly qualified staff, all of whom may be at additional risk. In particular ensure agency and bank staff are regularly risk assessed and tested since we know that employers should “take all possible steps to minimise staff movement between care homes, to stop infection spreading between locations” and that “subject to maintaining safe staffing levels, providers should employ staff to work at a single location”.
Make sure deployment does not target BME staff – something which appears to have been happening in some organisations. I have been told several times by BME staff that they feel they are “cannon fodder”.
Make sure staff know where to get speedy advice and support if they have safety concerns that are not being addressed. Telling staff they can take out a grievance (I have several examples) is a ridiculous response.
Ensure good Board oversight of both health conditions risk assessment and workplace treatment during COVID 19 so that assessments do not become a tick box
Be alert to the impact on staff mental health of the immense pressures on front line staff (and managers)
Undertake enhanced data collection and analysis (including of those risk assessment and infection rates) to assist proactive intervention
Finally, ensure the forthcoming NHS Restoration and Recovery process is informed by staff experience during the COVID 19 pressures.
That means serious attention to staff mental health. If ever there was a time for compassion and inclusion this is it or the NHS will lose staff to ill health or some will simply leave.
It also means serious attention to equality, diversity and inclusion. COVID 19 has shone a light on the sharply different experiences of BME staff in the NHS and their implications for infection and death. And it means reviewing the dominant recent strategy of primarily highlighting data and telling leaders they must do “something” about race discrimination rather than the painstaking work of identifying and disseminating effective interventions driven by accountability and support.
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