Limitations with HTMs need addressing

Having recently started a new job, by way of some sort of initiation I was tasked with writing an article for Health Estate Journal. While searching through the archives of the magazine seeking inspiration, I came across an article titled ‘The Missing Health Technical Memoranda’, first published on 3 November 2006. This article centred on the argument that there were significant gaps in the current suite of Health Technical Memoranda (commonly referred to as ‘the HTM’s’), and that more could be done to control the highest-risk activities within health estates. This piqued my interest, because 18 years later the issues raised in the article remain extant, and are in fact the same issues that I (and a lot of others) still face today. I endeavoured to find out why.

To understand why there are limitations with the HTMs, and why they only cover specific activities, in a specific way, perhaps we need first to understand the motivation behind writing them in the first instance. In other words, where did they come from?

Designed to ensure that healthcare estates complied

It is often thought that the HTMs were originally written to be Safe Systems of Work, as required by the Health and Safety at Work etc Act (HSWA) 1974, and inferred by the Management of Health and Safety at Work Regulations 1999. It would seem, however, that they were not. Instead, they are a series of documents written so that healthcare estates could comply with the requirements of the Care Quality Commission and the Health and Social Care Act. This line of thinking can be demonstrated by the flow chart diagram on page 5 of HTM 00: Policies and Principles of Healthcare Engineering (see Figure 1). You may notice a lack of health and safety legislation being cited.

This is an important distinction, because it could explain the driving force behind writing certain things into the HTMs and not others. While some health and safety has found its way in — for example with a cursory nod to the HSWA 1974 in Paragraph 2.5 of HTM 00 — initially the HTMs were primarily written to prioritise patient safety and welfare (as demonstrated at the bottom of the flow chart). While clearly this is no bad thing, it has unfortunately come at a cost, and the safety and welfare of the workforce operating and maintaining these systems is often overlooked. An example of this can be seen in HTM 02-01: Medical Gas Pipeline Systems, Part B: Operational Management, where a permit-to-work system is used not to control the health and safety risks of the work, as is common practice, but instead to ensure that there is no unintended interruption of medical gas supply.

What this means in turn is that the NHS, and the wider healthcare estate in general, are missing an overriding, centrally driven set of Policies, Procedures and Safe Systems of Work that do focus on the health and safety of the workforce. Until such a time that all the high-risk activities on the healthcare estate are addressed, and a central system is developed for the other areas of concern (think JSP 375 for the Ministry of Defence estate), each Trust will continue to be left to fend for itself, and in such an instance one of two things usually happens: either nothing is put in place, the workforce is still at risk, and accidents continue to happen, or Trusts end up paying out large sums for external companies to provide solutions to problems that could (and should) have been addressed centrally years ago.

The short answer is that we need to consider both the welfare of the patient, and the health and safety of the workforce (and any third parties who may be affected by their acts or omissions). The HTMs need to include all high-risk activities across the estate. HTM 00 and the other current suite of documents will need updating to reflect the importance of health and safety, rather than it being an afterthought.

There are several benefits to having a centralised suite of health and safety procedures for all high-risk activities across the health estate. Among these are:

1 Cost: Having a central set of procedures to refer to means that Trusts will be able to save time and money not having them produced at a local level. There will also be a marked reduction in HSE fines, enforcement notices, and fees for intervention for non-compliance with health and safety Acts and Regulations.

2 Commonality: Much in the same way that the HTMs already provide a common system of reference across the entire estate, expanding them to include a full set of health and safety procedures will ensure that everyone is working in the same way, to the same standards, and thus that benchmarking between Trusts will be possible. With a bit of tied-together thinking this could also feed into the Premises Assurance Model (PAM).

3 Accident reduction: Unfortunately, because of a lack of central direction, there are a lot of sites that are still not doing all that is required, and — as a result — accidents still happen. Having central procedures with a focus on ensuring health and safety compliance at a local level will reduce accident statistics.

So, what things specifically, do I think are missing?

Work at Height

Now this is often a controversial subject, but it really shouldn’t be. Work at Height is the biggest risk, not just in healthcare estates, but in the workplace in general. Falling from height is the most common cause of fatal injury in the workplace, accounting for approximately 25% of all fatalities annually. So why do some people still not take it seriously? In the past 10 years there have been over 500 successful prosecutions involving a breach of the Work at Height Regulations 2005. What is needed is a well-written, clear set of central procedures, guidelines, and training requirements, and some consistency in the way we approach Work at Height.

I sometimes get sneered at when I suggest implementing a HTM-style system for Work at Height, as it ‘isn’t engineering’, but why not? What do we think is happening when someone is working at height? They aren’t up there for the fun of it, but rather to perform work that will ultimately be engineering of one form or another. It’s thus incumbent on us to ensure that they are safe while that happens.

If people are familiar with the HTM hierarchical structure, familiar with the terminology, and familiar with the processes, then why not keep that consistency and commonality throughout all the different disciplines? This would also help to achieve compliance with the Work at Height Regulations 2005, and the Management of Health and Safety at Work Regulations 1999.

Confined Spaces

It is difficult to obtain precise statistics on fatalities in Confined Spaces in the UK, partly due to the fact that the HSE does not publish them (they end up being hidden in the construction statistics). However, according to various sources, it is estimated that an average of 15 people die each year in the UK as a result of work carried out in Confined Spaces, and that many others are often seriously injured.

Now this isn’t going to be another article on what a Confined Space is, and why they are so dangerous (there are many existing such articles). As with Work at Height, however, a well-written set of procedures, guidelines, and training requirements, and a consistent approach to controlling Confined Spaces, are required — including the ability to audit and monitor the management system, and a HTM-style system is best placed for that. Again, I encounter reluctance at times for it not being an engineering discipline, but again, my answer always remains the same. What is it you think we are doing in these spaces if not performing engineering works?

Unfortunately, the lack of understanding of the requirements of the Confined Spaces Regulations 1997 regularly has an impact on my NHS clients. Only last year I was helping an NHS Trust to implement a Confined Spaces management procedure after it received multiple improvement and prohibition notices from the HSE (not to mention the six-figure fines).

The one that should hit home however, is the HSE report from January this year of an NHS engineer entering a drain on a hospital site, being overcome by gases, and unfortunately suffering from severe permanent brain injuries. Again, the Trust received a significant fine, but — more importantly — that man and his family have been impacted forever.

Mechanical (Boilers and Pressure Systems)

Boilers and Pressure Systems are an often overlooked or misunderstood Safe System of Work. People often think that because, for example, they can demonstrate compliance with the Pressure Systems Safety Regulations (PSSR) 2000 (i.e. they have a written scheme of examination for relevant systems, and they are inspected at the required frequencies), they have covered all the bases. This isn’t necessarily true. There may be some high-risk mechanical systems that do not fall under PSSR, (e.g. low temperature hot water) that will still require maintenance and examination. There is reference to safe systems of work in PSSR, as follows: ‘Before each examination take all appropriate safety measures to prepare the system for examination’. Therefore, a risk-based approach is required to identify systems and equipment that will need a formal approach to making them safe to work on.

Inspection by a Competent Person

A critical element in any Safe System of Work is the ability to make a system safe for operatives to work on or in, and, where PSSR applies, for a Competent Person to carry out their inspection. For example, the need — before setting people to work on a steam system — to ensure that everything is correctly isolated/cooled/de-pressurised/drained etc, and that there is no remaining risk to the person performing the work. Unfortunately, this is often largely left to chance, with accidents still a regular occurrence — for example, valves being only shut, and not correctly secured and signed (with safety locks and safety signs), or systems being worked on before they are sufficiently cooled.

There was an incident where a maintenance worker at a hospital received serious burns to the lower half of his body while stripping down a steam boiler, resulting in permanent disabling injury. Again, the Trust received a fine, and yet again, that man and his family have been impacted forever.

There will often be an overlap with working at height, and confined spaces as well. For example, working on high-level pipework or on top of a boiler (away from a fixed walkway), or carrying out an internal inspection of a large steam boiler. Again, with a tied-together and centralised management system and set of procedures to support it, all these things can be covered safely.

I haven’t even begun to cover all the bases here, and there are plenty more topics for discussion when it comes to Safe Systems of Work in the world of engineering and estates management However, I hope this has provided food for thought, and will hopefully be the catalyst for a conversation to begin. In conclusion, now is the right time to refresh the Health Technical Memoranda and update them with everyone’s safety — and not just that of the patients — in mind.