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August 16, 2010

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Training and career development – A dose of surgical spirit

Challenged by successive governments to act as an exemplar on health and safety, the NHS is making gradual progress towards this goal, says Julian Topping, who describes how the varied training needs of such a large and diverse workforce are met.

As a never-ending round-the-clock service, the NHS probably offers wider and more varied opportunities for staff to suffer accidents than almost any other non-industrial workplace. The organisation deals with poisons, radiation, sharps, contaminated waste, transporting sick people from one place to another – and that’s just a few of the hazardous activities carried out by its employees.

Just consider the logistics of keeping the floors clean in a building that is in use 24 hours a day and, for most of that time, full of patients, staff, visitors and contractors. Indeed, more than 2 million people are estimated to pass through the doors of NHS establishments every day.

Responding to a report on NHS health and safety by the National Audit Office (NAO) in 1996,1 the then chairman of the Public Accounts Committee noted that the NHS was clearly a very dangerous place to work and underlined that the organisation must manage health and safety properly for the benefit of patients, visitors and staff.

The NHS has come a long way since that report, with improvements identified across the board in a follow-up report by the NAO seven years later.2 This report also pointed out that there was still a long way to go if the NHS was to become an exemplar employer in the field of staff health and well-being – a challenge set by successive governments since the early 1990s. The estimated number of accidents in 2003 was still in excess of 135,000 and one issue picked up in both reports was that of sufficient training for staff, at all levels, covering their duties and responsibilities in relation to health and safety.

Training in health and safety is a legal requirement under the Health and Safety at Work, etc. Act 1974, which requires employers to provide whatever instruction, training, information and supervision is necessary to ensure, as far as reasonably practicable, the health and safety of their employees at work.

This, in turn, is expanded on by the Management of Health and Safety at Work Regulations 1999, which identify specific situations where health and safety training is particularly important, including: induction; where tasks have increased, or specific risks are associated with them; and where training needs updating or refreshing.

So, the need to provide training for employees starts with an introduction to health and safety as part of induction, and moves, via general training in rights and responsibilities, through more specific training for those working in higher or particular risk areas, such as radiology, and on to the highest levels of training and qualification expected of health and safety managers.

Central to ensuring that staff are trained, and that the organisation is compliant and takes the issue seriously, are training for senior managers and the board, as well as the involvement of employee health and safety reps and the health and safety committee in agreeing policies for managing health, safety and risk.

Effective health and safety management is recognised as being a key part of delivering a quality service and good patient outcomes, so, on the whole, the NHS takes training seriously. This is not to say that training and the training budget don’t come under scrutiny at times when finances are being reviewed and the service is facing increasing financial pressures. For this reason the most innovative organisations are developing new ways of delivering training to ensure that they continue to maintain high standards.


While the HSWA imposes a duty on all employers to take responsibility for the health and safety at work of their staff, it is often forgotten that the Act also imposes a duty on employees in terms of complying with the safe systems of work put in place by the employer, and looking after their own and their colleagues’ health and safety.

Guidance issued to the NHS by the Department of Health in the wake of the 2003 NAO report makes it clear that all new staff should receive training in health and safety and the management of risk, and that, to facilitate this, employers should adopt a strategic approach to induction and training needs.

All staff in the NHS should currently be receiving induction training, which includes the rudiments of health and safety law, management of risk, and their duty to comply. However, all-too frequently when talking to staff, it is obvious that they think of health and safety as something that is ‘done to them’ at work rather than something that they are, in many ways, jointly responsible for delivering along with their employer.

This calls into question the effectiveness of some of the current induction and on-the-job training that is being delivered. Half an hour, delivered by a health and safety manager or rep, as part of an increasingly packed day of induction, during which so much information has to be assimilated, is a very limited opportunity to embed good health and safety practice in new members of staff.

On-the-job training

It is because opportunities at induction are usually so limited that follow-up training, delivered as soon as possible once the employee starts working in their new environment, is so vital. This is the ideal chance to build on the general introduction during the induction process and to ensure that staff understand the importance of assessing and managing risk, complying with the risk assessments that have already been carried out, reporting any accidents in the appropriate manner, and being aware of where to go for further advice. It is also essential to show those being trained how their reporting of accidents influences the way the organisation works and assesses risk, and why the collection of such data is so important.

Provision of this training brings its own difficulties, with staff often finding it difficult to get time away from their work, and line managers who are reluctant to free up the time of their staff for what they see as something that is not a key part of their duties.

Increasingly, NHS organisations are addressing this reluctance on the part of both managers and staff by incorporating the management of, and attendance at, health and safety training into annual objectives. Via this method they are providing all staff (after all, managers are members of staff as well) with an added incentive to comply and have it recognised in their appraisal. In organisations where line managers fail to see the importance of the training to the wider organisation, it may also be necessary to address this as part of line managers’ own training.

Job-specific training

At this stage in the process, a new member of staff should have received a short training session at induction, followed by a more general and much longer session once they have started their new job. Now, an assessment should be made to see if their job warrants further, more job-specific training.

If, for example, the new employee is going to be working with ionising radiation there will be further requirements for training, as set out in regulation 14 of the Ionising Radiation Regulations 1999 (IR1999), and regulations 4(4)a and (4)b of the Ionising Radiation (Medical Exposure) (Amendment) Regulations IM(ME)R(A) 2006. These require the employer to provide suitable and sufficient training for all employees engaged in work with radiation and ensure that staff have received training in the care and use of dosimeters and understand their legal obligations and entitlements.

The range of job-related health and safety training that needs to be carried out in an NHS organisation is wide and varied and could cover: safe disposal of sharps; assessing risk when lone working; fire; safe disposal of infected cadavers from the mortuary; slips, trips, and falls; and disposal of waste. The range of legislation that health and safety managers, staff representatives and health and safety committees need to be familiar with is also varied and frequently being updated and amended.

For all of these people, it is not easy to keep up to date with all of the new UK and European legislation, and mandated action from the Department of Health and its arms-length bodies, such as the Security Management Service, which deals with issues of violence and aggression against staff.

Updating and refreshing training

Experience within the NHS and recommendations from both NAO reports indicate the need for staff to receive regular refresher training, both in the overview of health and safety and in any areas particular to their own work.
Good practice in the NHS indicates that the training should be delivered every third year for maximum effectiveness, and advice to the service from both the Department of Health and NHS Employers recommends that trusts should have identified the need for health and safety refresher training as part of their health and safety management policies and have in place a system for this to be managed.

NHS organisations also frequently refresh training when staff move from one job to another, or start working with new or unfamiliar equipment.

Health and safety managers

For much of the 1990s and before, health and safety did not enjoy a particularly high profile within the NHS, which was covered by Crown immunity until 1 January 1990. During this period, the NHS was not well-resourced with health and safety managers, and it took the prosecution of a West Country former trust in 1997, for failing to have put in place measures to ensure the health and safety of employees, to raise the profile of health and safety within the overall institution.

Now, there is not a trust that does not have in place someone who meets the MHSWR 1999 requirement for a competent person to assist employers in complying with the requirements of legislation.

Taking into account the definition of a competent person in the MHSWR, the Department of Health has set out a target for all NHS health and safety managers to be qualified to at least CMIOSH level.

Training senior managers

Ultimate legal responsibility for the management of health and safety in any NHS organisation sits with the chief executive. In most trusts the day-to-day oversight of health and safety at board level sits with one of the directors, who ensures compliance through working with the health and safety managers, health and safety committee and safety reps.

The Department of Health recommends that board members undertake IOSH’s one-day Directing Safely course to provide them with a level of knowledge and understanding of the subject, which is appropriate to their responsibilities. This will also provide directors with the necessary insight to be able to discuss health and safety reports when they are tabled at board meetings – which, in most trusts, now happen at least quarterly – and to ensure that the organisation’s health and safety strategy and policies are appropriate and sufficient to meet the risks identified by their professional staff.


One of the recommendations from the NAO reports was that the NHS should improve its record-keeping in relation to training provided for staff. The NHS in England considered implementing a scheme along the lines of the Welsh Manual Handling Passport, which would allow training to be recorded in such a way as to be transferable with the employee when they move to employment with another NHS organisation.

The sheer logistics of devising such a scheme, obtaining agreement, and implementing it effectively in such a large and widespread organisation mean that this has not yet happened. However, there is still the possibility that developments in the electronic staff record may one day allow recording of training and the transfer of training records from one organisation to another. In the meantime, it is essential that all NHS organisations maintain records of training provided alongside their records of risk assessment and accidents.


The management of training within the NHS is not perfect by any means but evidence suggests that the organisation is making strides to improve it. Implementation of the Corporate Manslaughter and Corporate Homicide Act has focused the minds of many, and has provided an ideal opportunity for boards to revisit their strategies and policies to ensure they are compliant. This should be an ongoing process and training should also be a key component of ensuring that safety is recognised as a major responsibility of everyone who works in the Service. The NHS may not yet be the exemplar that successive governments have challenged it to be, but it is a lot nearer to that goal than it was 20 years ago when it lost its Crown immunity.

1     National Audit Office (1996): ‘Health and Safety in NHS Acute Hospital Trusts in England (HC 82)’ – e-mail: [email protected] for details
2     National Audit Office (2003): ‘A Safer Place to Work: Improving the management of health and safety risks to staff in NHS trusts (HC 623)’ –

Julian Topping is programme lead for health, work and well-being at NHS Employers.

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