By Paul Grime, Chair of the Safer Needles Network

There are many competing priorities for investment of scarce resources in today's ever changing health service.  Any proposal for change must therefore be sufficiently robust and persuasive to attract attention, to merit serious consideration and to secure successful acceptance. 

This document outlines the financial, legal and regulatory case for healthcare employers to invest in safer systems of work to protect staff, patients and visitors.  

Safer systems of work may include:

• Data recording systems for surveillance of exposure incidents to facilitate organisational learning and risk reduction

• Regular education and training for healthcare workers in safer systems of work

• Provision of medical devices incorporating safety engineered protection mechanisms.

The arguments presented here can be adapted and supplemented with local data and information, for example on locally reported exposure incidents and outcomes, to substantiate a local business case.

Cost Considerations

Direct cost comparisons for introducing new systems often show an adverse cost variance, which discourages NHS trusts from even considering investments to protect staff and patients, particularly in the current financial climate.  However, such comparisons often do not take account of several important points:

• 1. Savings on payments for the Clinical Negligence Scheme for Trusts for implementing measures to protect patients and staff.

• 2. Safer medical devices are inherently more expensive for manufacturers to produce. However, it is likely that unit costs will come down with economies of scale, as sales increase as trusts comply with national guidance and legislation.

• 3. Possible savings due to changes in usage patterns of the mix of available devices (e.g. straight needles vs winged cannulae for blood collection). Calculations are inevitably based on past usage figures, which may well change with the introduction of safer systems of work.

• 4. Possible larger retrospective discounts calculated on a sector rather than a trust basis, if a number of trusts are introducing new systems simultaneously.

• 5. Savings from the reduction in the rate of exposure incidents. A trust with 5000 staff can spend around £100,000 annually on managing exposure incidents, including the costs of blood tests, lost staff time and post-exposure prophylaxis, but excluding litigation costs. A recent large study commissioned by the Scottish Executive demonstrated that 41% of sharps injuries could probably and 14% could definitely be prevented by the use of safety devices. Applying these figures of to a trust with 5000 staff gives estimated annual savings of £14,000 - £42,000.

• 6. Trusts have sometimes rejected business cases for introducing safer systems of work on cost grounds, only to make the proposed changes subsequently in response to adverse incidents that could have been prevented by safer systems. As well as being more costly to deal with, such incidents attract attention from the Health and Safety Executive, litigation, prosecution and damaged reputation for the trusts concerned. Safer systems of work protect patients, visitors and staff, and reduce the risk of further legal action.

Legal and Regulatory Considerations

A plethora of statutes, regulations and national (and international) guidelines compel healthcare employers to protect staff, patients and visitors through safer systems of work.

• 1. NHS trust's are committed to meet the core standards in Standards for Better Health (Department of Health 2004). The Healthcare Commission will assess trusts' performance against these standards, from 2006 onwards. The first domain in Standards for Better Health is "Safety".

Core Standard C1 states:

"Health care organisations [must] protect patients through systems that:

(a) Identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from analysis of incidents.

(b) Ensure that patient safety notices, alerts and other communications concerning patient safety, which require action, are acted upon within required timescales." 

Even more specifically, core Standard C4 states:

"Healthcare organisations must keep patients, staff and visitors safe by having systems to ensure the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment."

• 2. In June 2003, the National Institute for Clinical Excellence published guidelines for the Prevention of Healthcare Associated Infections in Primary and Community Care. Recommendation SP (Standard Principle) 24 states:

"Needle Safety Devices must be used where there are clear indications that they will provide safer systems of working for healthcare personnel."

The guidelines acknowledge that safety devices not only minimise the risk of operator injury but also "downstream" injuries following the disposal of sharps, involving housekeeping or portering staff.

• 3. In January 2005, NHS Employers issues updated guidance on The Management of Health, Safety and Welfare Issues for NHS Staff. Chapter 19 specifically recommends:

"the availability of safety engineered devices to all healthcare workers in the place of work, where proper risk assessment has identified that such devices will reduce the risk of blood and body fluid exposure". 

• 4. In 2000, the Department of Health report An Organisation with a Memory concluded:

"The NHS often fails to learn the lessons when things go wrong... Yet the potential benefits ... are tremendous - in terms of lives saved, harm prevented and resources freed up for the delivery of more and better care. ...if the NHS is successfully to modernise its approach to learning from failure, it needs to develop:

• i. Mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice

• ii. A much wider appreciation of the value of a systems approach in preventing and analysing and learning from errors.

• 5. The Health Improvement and Protection Bill (October 2005) includes a draft Code of Practice which requires (amongst many other things) policies that encompass:

"The provision of medical devices incorporating sharps protection mechanisms"

This recommendation is included in the section on "patient care", rather than "healthcare workers".  The document states that:

"It is the Government's policy that the relevant requirements of the code of practice must be put into effect by all NHS Trusts.  There will therefore be a new statutory duty on NHS health care organisations to make arrangements to put the provisions of the code into practice, backed up by action if there are significant failings in relation to the code."

• 6. In 2004, in a legal ruling against the Scottish Ambulance Service, three appeal judges ruled that cost grounds alone cannot be a reason not to purchase safer sharps devices, as this breached European health and safety laws.

Summary

• NHS trusts' financial situations cannot be ignored but all current priorities must be balanced. 

• There are well documented cases of UK health care workers acquiring blood-borne virus infections through occupational exposure.  At least 4 UK nurses are known to have died from occupationally acquired HIV.  Given the high population prevalence of hepatitis C, the rising incidence of HIV and the increasingly interventional nature of healthcare, it is not inconceivable that it could happen again.  It is likely that it would be trusts' Chief Executives who would be answerable to any claim brought against a trust for corporate manslaughter. 

• The costs of investing in safer systems of work are often calculated on a worst case scenario.  The true costs are likely to be lower although some financial investment is likely to be required in the short term. 

• The costs of rejecting any opportunity to make healthcare safer, to comply with national and international guidance trusts' obligations to its staff, its patients, and to the Healthcare Commission are not inconsiderable and are likely to be greater in the longer term.

Paul Grime, Consultant/Honorary Senior Lecturer in Occupational Medicine,

Royal Free Hospital, London.  February 2006