Paper submitted by Professor Ewan B Macdonald to Lanarkshire Health Board Meeting 28 th September 2011 Lanarkshire NHS Board, Kirklands, Fallside Road, Bothwell, Glasgow, G71 8BB Telephone 01698 858300 www.nhslanarkshire.org.uk SUBJECT SALUS ANNUAL REPORT 1 st APRIL 2010 to 31 st MARCH 2011 1. PURPOSE OF REPORT This paper is presented to the NHS Lanarkshire Board to provide members with an update on the progress of Occupational Health and Safety for 2010/11 and accompanies the Salus 2010/11 annual report. 2. CONTENT/SUMMARY OF KEY ISSUES The annual health and safety report has been constructed to identify and document the Occupational Health and Safety Department s activities and the Health Boards health and safety performance for the 2010/11 financial year. This paper summarises the main highlights of the year, the key issues, and the major focus areas for 2011-12. A presentation will accompany this paper. 2.1 HIGHLIGHTS 2.1.1 Occupational Health Evaluation of Line Managers and Human Resource staff demonstrated an overall satisfaction level of 90% in regard to occupational health reports following management referrals. This will be monitored over the next 5 years to ensure continual improvement. Cancellations and DNAs have reduced significantly by 9% and 14% respectively against last years figures. Telephone consultations are utilised as an appropriate alternative where applicable. Work related Mental Health issues have reduced by 18% in the last year to 65, as have needlestick incidents which have reduced by 8% to 145. Absence rates remain stable and a partnership approach is taken to continue to maintain and improve absence levels. Compliance with the EASY process has improved by 5.4% this year. Electronic notifications to EASY can now be made through a dedicated hyperlink hosted in Firstport. The 2010/2011 Annual Seasonal Flu programme was delivered from within existing Salus resources and achieved an uptake of 30% across staff groups. This was double the average yearly uptake, (excluding 2009/2010 H1N1). The Scottish NHS Boards average uptake for last year was 23.7%. Health and Safety Annual Report 2010-11 1
2.1.2 Health and Safety Positive feedback from the Health and Safety Executive (HSE) after a review of Legionella controls at Hairmyres Hospital. The visit resulted in a letter noting exemplary controls in place. Major inspection undertaken by 3 visiting HSE Inspectors over a 5 day period at Monklands General Hospital including a ½ day review of the West of Scotland Laundry activities. HSE Inspectors noted multiple instances of best practice. Compliance programme for 2010-11 completed. Monthly Occupational Health and Safety report reviewed to provide detail on KPI s, incident trends, and staff safety and patient non clinical incident data. Staff incidents consistent in 2010-11 (1667) in comparison with 2009-10 (1659) (+8). Audit of the 465 Control Books was completed with only 7 Control Books deferred due to planned movement of staff groups. 4% scored less than 61% (red action plan agreed and re-assessment within 6 months), 20% scored between 62% and 80% (Amber action plan agreed and re-audited within 12 months) and 76% scored 82% and over (green and re-audited within 24 months). Health and Safety training continued to receive a high priority, with a programme of courses delivered throughout 2010/11. New E-learning courses developed and delivered for Moving and Handling and PaMOVA reducing class room based induction training. 2.1.3 Healthy Working Lives (HWL) NHS Lanarkshire has 16 HWL award registrations across its constituent parts. This comprises 5 Gold, 4 Silver and 7 Bronze awards. NHS Lanarkshire achieved a 35% positive response against an NHS Scotland average of 11% in relation to staff lifestyle checks. 300 carried out in 2010-11. NHS Lanarkshire achieved a 21% positive response against an NHS Scotland average of 13% in relation to awareness raising regarding mental health issues. 1,500 subsidised leisure memberships with North & South Lanarkshire Leisure. 2.1.4 Added Value to NHS Lanarkshire Throughout 2010-11 Salus have continued to provide additional support to various NHSL objectives. The Return to Work Service team has continued to engage the workless population in an aim to improve public health and support individuals back to employment. The service is delivered by Salus across various parts of the UK. This is reported as external business to the Salus Board. Health and Safety 2010-11 Annual Report 2
2.1.4 Added Value to NHS Lanarkshire Salus lead the national Fit for Work service (funded by Scottish Government & DWP), coordinating activity across 14 health Boards with the aim of supporting employees of small and medium enterprise back to work from sickness absence. 2010-11 saw circa 2,500 employees supported. Salus met the CRES target and the additional 1.1m operational surplus target, attracting over 7m income from external business in 2010-11. 2010-11 saw a rigorous workforce planning review which resulted in Salus downsizing by 16% and reconfiguring to meet service objectives. 2.2 KEY AREAS WITH OPPORTUNITY FOR IMPROVED PERFORMANCE 2.2.1 Occupational Health EASY Current compliance rate shows that 28% of absences are not being reported to EASY. There is the potential for further reductions in sickness absence through improved compliance. The HSE identified areas for improvement during the five day HSE visit by the 3 Inspectors in November 2010. The main areas to be progressed are noted in the next section of this paper. 2.2.2 Health and Safety 59 work related incidents reported to the HSE in 2010-11 in line with The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR), (including 1 patient RIDDOR). 48 of these were over 3 days lost working time, 8 major injuries and 3 Dangerous Occurrences (specified near miss accidents). This compares with 58 RIDDOR s reported during 2009-10. Staff injuries higher in 2010-11 from the previous year (488 compared to 451) (+37/8.2%). Patient non clinical incidents rose (7224 in 2010-11 compared to 6661 in 2009-10) (+563/+8.4%). Reported patient non clinical injuries increased from 1113 (2009-10) to 1453 (2010-11). Falls remain the main category of reported patient non clinical incident and injury with 4530 patient falls reported for 2010-11 in comparison to 4206 for 2009-10 (+324/ +7.7%). Patient non clinical injuries attributed to falls increased from 811 (2009-10) to 1087 (2010-11). 2.2.3 Healthy Working Lives Increase engagement with local enterprises to provide work related health support. Health and Safety 2010-11 Annual Report 3
2.3 FOCUS AREAS IN 2011-12 2.3.1 Occupational Health Review of EASY service processes including the algorithm, sickness absence meetings, reporting, etc to identify opportunities for improvement. Compliance- Quarterly compliance reports on EASY will be provided to senior managers within NHSL. Detailed summaries of the audit findings and outcomes to be issued to Managers and Human Resources in the 2 nd quarter of 2011. Promotion of continued support for NHSL staff throughout organisational change. Introduction of Information Technology based health promotion lifestyle package for NHS Lanarkshire staff. NHSL wide road shows to highlight and promote EASY, Occupational Health and Healthy Working Lives. Progression of HSE voluntary action plan: Systematic use of safe sharp devices to decrease the danger risk of accidental needle stick injuries. Review of NHSL Latex Gloves Policy for the selection and use of disposable gloves for clinical activities with migration to nitrile gloves, as far as practicable. Review of current protocols and strategy on the monitoring of work related irritant hand dermatitis e.g. dermatitis induced through hand washing, use of soaps, detergents, alcohol gels, etc. 2.3.2 Health and Safety Progression of HSE voluntary action plan: Improvement in pedestrian safety and deliveries at Monklands. Workplace transport assessments progressed for Monklands General Hospital and all NHSL Premises (88 sites). Corporate Process for the Control and Management of Contractors and the Management of Asbestos. Working with Directorates to develop clear, agreed generic standards of good management practice for a range of workplace transport issues. Liaison with the Acute division via supporting the Falls Groups for the 3 Acute sites on gathering specific data on why patients are falling and trends related to injuries/incidents occurring and reviewing trend data to identify any possible additional intervention strategies and improvements to current processes. Maintain the Compliance programme and ensure corrective actions are implemented across NHSL as far as reasonably practical. Health and Safety 2010-11 Annual Report 4
2.3.3 Healthy Working Lives Retention of the valued Employee Counselling Service in order that anonymous mental health support can be offered to staff. Increase the further attainment of Bronze awards and conversions from Bronze to Silver and Silver to Gold. 3. CONCLUSIONS A significant factor in the very good overall progress made in 2010-11 was the commitment and collaboration of Directors, Senior Managers, Line Managers, Human Resources, Occupational Health, Staff side Representations and the deployment of NHS Lanarkshire s policies and internal/external support services. Salus continues to remain committed to improving the health and safety of all persons who come into contact with NHS Lanarkshire s services and/or premises under our control especially staff, patients, visitors, general public, contractors, suppliers, etc. The EASY service continued to provide staff with support when ill and continued to be effective in helping them stay at work or return to work more quickly at the same time as continuing high levels of staff and managers satisfaction. The focus for 2011-12 will be to: Build upon the very good overall progress made in 2010-11. Supporting managers and staff. Continue working in partnership with Divisions, Managers and Staff Side Representatives to: Drive further improvements in accidents and injuries to staff and patients. Reduce staff sickness absence. Promote compliance with EASY. Continue to impact work related mental health issues. Progress actions arising from the HSE audit report from Monklands. 4. ACTIONS For the Board to note the annual report and approve the proposed initiatives and ongoing work commitments. Health and Safety 2010-11 Annual Report 5
5. FURTHER INFORMATION For further information regarding any aspect of this paper or for further information, please contact:- Professor Ewan B Macdonald OBE, Deputy Director of Human Resources (Occupational Health and Safety), Director of Salus, NHS Lanarkshire, 01236438181, PA - Margaret Gillon 01236 438175. Health and Safety 2010-11 Annual Report 6