First aid: time for surgery?
Howard Fidderman looks at an HSE discussion document that may herald fundamental changes to the UK's first aid at work regime.
The changing nature of work, employers' increasing operation in public areas and developments in equipment during the past 20 years have prompted the HSE to start a major review of the UK's first-aid regime. It is seeking stakeholders comments1 on the Health and Safety (First-Aid) Regulations 1981 (FAW) and its accompanying Approved Code of Practice (ACoP) and guidance to see how they can be developed to meet current needs.
Most employers are covered by the FAW Regulations, under which they must provide the equipment, facilities and personnel needed to give first aid at work and must tell their employees about the arrangements for first aid (offshore installations are subject to a separate regime) (see box 1).
The HSE's discussion document covers eight main areas:
Making the regime more effective
The need for a review was highlighted by an evaluation of the current system published earlier this year2. This research found that employers agreed that the FAW regime is effective, although their implementation of the requirements could be improved. Employers said that factors affecting implementation included criticism or uncertainty around:
One option being considered by the HSE is to establish a cost-benefit case for the Regulations. Participants in the evaluation generally thought benefits were reasonable compared with the costs. The research estimates that a first-aider costs £505 a year and there is an economic benefit if they save an average of 1.8 days of lost time. The HSE acknowledges: "There is no hard evidence on the benefits to workers who have used the services of a first-aider as the effectiveness of the intervention by a first-aider is rarely recorded."
Smaller and lower-risk organisations have the greatest misgivings about the cost-benefit ratio, particularly around training and time off for first-aiders. The evaluation report recommends addressing this by allowing employers more flexibility in matching the number of first-aid personnel to the risk.
More broadly, the HSE wonders if the Regulations should be integrated with the Management of Health and Safety at Work Regulations 1999 and the Workplace (Health, Safety and Welfare) Regulations 1992. Since the FAW Regulations were introduced, health and safety legislation has moved from a system based on prescription to one based on the assessment and management of risk. Integration would encourage employers to identify first aid as part of their risk management regime, but it might also dilute its importance. The evaluation ruled out integration in the short term, but saw it as the "logical and appropriate goal".
Members of the public
Although employers have a duty under the Health and Safety at Work Act (HSW) to protect the public from risks arising out of their undertaking, they are not required by the FAW Regulations to consider the public when assessing their first-aid needs or provision (although the HSE strongly recommends it). Increasingly this is an issue with the expanding number of public areas in which employers operate, including shopping centres, entertainment and sporting venues, and transport interchanges. Nine in 10 employers in the research thought that organisations should consider the public when assessing first-aid needs but thought that an extension of the FAW Regulations to cover the public would be impracticable. The HSE takes a similar view, in that an extension of the FAW Regulations would need a change to the HSW Act (and is therefore out of the question).
The HSE thinks it is reasonable to expect companies in a large shopping centre to pool their resources to ensure adequate first-aid provision for the public, but accepts it might be disproportionate if all small shops had to have a first-aider to take care of customers. Identifying who would have the duties to provide public first aid, enforcement, costs and potential litigation would also be problematic.
Defibrillators
The HSE believes that the availability in public places of automated external defibrillators (AEDs) and personnel trained to use them would increase the chances of survival of a person who suffers cardiac arrest. Employers with large numbers of the public on their premises, such as retailers, may face a strong case for AEDs if they include the public in their needs assessment.
The public aside, the risk of a heart attack, albeit not caused by work, in low-risk workplaces such as offices, is likely to be higher than that of a serious accident. In these circumstances the HSE thinks an employer might conclude that the provision of an AED and additional training for first-aiders is justified.
Training changes
A qualified workplace first-aider must have attended a course involving 24 hours' "contact" time, usually spread over four days, and pass an examination. They must also take a 12-hour refresher course every three years. Where a first-aider is not required, employers must appoint a person to take charge of the first-aid arrangements. The HSE advises employers to consider sending such "appointed persons" on a short - usually four-hour - course in life-saving. Such courses, unlike those for first-aiders, do not require HSE approval.
The research revealed that some companies found it difficult to release employees for a four-day course. They were also confused about the roles of first aiders and appointed persons, but supported compulsory training of the latter. Many trainers and first-aiders felt the three-year gap between courses is too long, a view that was supported by an HSE literature review3.
The HSE believes that the content of current first-aid courses "is perhaps over-influenced by the historical predominance of heavy industry with the attendant risks of major injury". Most first-aiders will work in the service sector where injuries are more likely to be minor. "Overall," says the HSE, "there is little support for maintaining the current training arrangements in their existing format."
There is agreement on the need for:
The HSE presents three options. It does not favour either the retention of the current system or requiring each workplace to have at least one qualified first-aider who has completed an emergency first-aid course.
The third option, which the HSE supports, is to leave an employer's duty to assess its first-aid needs unchanged, but with the addition of: a clear distinction between the categories of appointed person and first-aider; greater gearing of first-aider training to the needs of the business; two main training options for first-aiders; and restriction of the role of an appointed person to taking charge of first-aid arrangements, including the equipment and calling the emergency services.
The main training options would be a six-hour emergency first-aid course and a 16-hour first aid at work course, each with six to eight hours' annual refresher training (see table 1). Both courses will be subject to approval arrangements. The HSE has not proposed a training requirement for appointed persons.
The HSE claims that the 16-hour course will cover most of the same elements as the current course, even though it is shorter. It will have a greater emphasis on life-threatening injuries or illnesses, and will be stripped of "non-essential detail", allowing the training to be simplified and focused. There will be no change to the delivery of additional training, for example first-aiders who work in remote locations will still need to be able to stabilise fractures.
The first-aid box
The FAW Regulations require employers to provide adequate first-aid equipment, which the ACoP interprets as including "at least one first-aid container supplied with a sufficient quantity of first-aid materials suitable for the particular circumstances". The HSE's guidance suggests, as a minimum, a list of contents that mostly concerns minor cuts, bleeding from major wounds and eye injuries.
This appears to confuse some employers who:
The HSE offers three options with the aim of making the situation unambiguous:
Medicines
The HSE's current guidance recommends that employers do not keep medicines in the first-aid box, reflecting the view that the use of medicines is normally outside of the scope of first aid. Nevertheless, there is no law that prevents employers from making medicines available to their employees and, as the HSE notes, many do, either through a vending machine or through a responsible person, who is often a first-aider.
Although the HSE agrees it would be simpler to keep medicines in the first-aid box and make first-aiders responsible for their administration, it fears this might encourage litigation and imply that first-aiders have diagnostic skills. It asks whether first-aiders should ever be responsible for the distribution of over-the-counter medicines to employees and, if so, whether the medicines should be kept in the first-aid box, a separate container (to emphasise that they are not within the scope of first aid) or elsewhere.
Potential problems
For the most part, the discussion document proposes practical options for change that recognise the shortcomings of the first aid at work regime. But a few of the HSE's preferred options are potentially problematic. For example, employers may well be more likely to release staff for first-aid training that is geared to the needs of their individual business, but this must not be at the expense of skills and qualifications that are universal. Workers, after all, change employers.
More importantly, employers claim to be confused about the distinction between a qualified first-aider and appointed person. Yet the HSE's response - and that of the evaluation report also - is to propose splitting the first-aider qualification into two and downgrading the appointed person, leaving the confused employer with not just two, but three levels of first-aid personnel with which to grapple. This begs the question of whether or not the basic first-aider will be anything more than a glorified version of the current appointed person?
The document is vague on other issues. In particular, it does not offer concrete options on the ratios of appointed persons and first-aiders to employees, even though this is one of the two most frequently asked questions on first aid that the HSE's InfoLine receives. Nor is there a clear commitment to sector-specific guidance, one of the recommendations of the evaluation report.
Quality questions
There is little in the document that directly addresses the questionable quality of some first-aiders. For sure, the move to annual refresher training is imperative. But the HSE does not engage with the questionable way in which first-aiders "qualify", with approved organisations not just running the courses but also using their own trainers as examiners for part of the test. First-aid training is a lucrative industry: what incentive does a training organisation have to fail its own candidates and gain a reputation for having a lower pass rate than its competitors? Similarly, what incentive does a doctor who is retained by the training organisation on a freelance basis to test medical knowledge have to fail candidates?
The UK needs more, not less, first-aiders, so why does the HSE fail to invite suggestions for encouraging participation? Some companies, for example, offer honorariums for first-aiders; others offer salary or benefit enhancements.
It is to be hoped that any ensuing consultative document looks in greater detail at different methods of training delivery. Currently, many of the 24 hours' "contact" training first-aiders receive are devoted to theory: one option might be to encourage distance learning of the theory through interactive electronic technology, freeing up "contact" time for practice.
Compliance in "spirit"
Finally, there is the perennial problem of compliance: the evaluation report was clear that, while employer awareness of the FAW Regulations was good, compliance was more "in spirit" than to the letter of the law. Improvements to the ACoP and guidance may well improve this situation, but the attitude of the HSE towards enforcement of first aid may also need to harden: the FAW Regulations have featured in just 50 enforcement notices since April 2001 and five prosecutions since April1999.
Although the HSE is disappointingly circumspect about many of its options for reform - even for a discussion document - it is safe to assume that this document will result in important changes to the first aid at work regime that will have a bearing on nearly all employers and employees. For this reason it is particularly important that the HSE receives a large, representative response, not least because it appears to have a genuinely open mind on what it might do. If responses to the discussion document show changes are needed, a full consultation will follow.
Howard Fidderman is editor of HSB and a qualified first-aider.
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The Health and Safety (First-Aid) Regulations 1981 require employers and the self-employed to carry out an assessment to ensure that adequate and appropriate equipment, facilities and personnel are provided to enable first aid to be given to employees, taking account of the circumstances of the employer's undertaking or business. Based on the assessment, an employer must arrange for first-aid provision through appointed persons and/or first-aiders. A first-aider is someone who has undergone a training course in administering first aid at work. If the first-aider is temporarily and exceptionally absent, an employer can discharge its duties through an appointed person, who will:
Appointed persons should not attempt to give first aid for which they have not been trained and should be available all the time that people are at work on site. A first-aider can undertake the duties of an appointed person. In low-risk undertakings, first-aid provision may simply
require an appointed person and a first-aid box, but the number of
first-aiders or appointed persons will depend on the circumstances of each
particular undertaking. The HSE has offered advice on appropriate numbers. |
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Legislation 1.Should the First Aid at Work Regulations (FAW) be incorporated into other health and safety management Regulations? 2.What benefit, if any, would incorporation lend to employers in assessing and making their first-aid provision? 3.Do the FAW Regulations make clear the role and duties of employers, first-aiders and appointed persons? Guidance 4.What additional guidance should the HSE give on making a first-aid needs assessment? 5.What other areas of first aid at work does the HSE need to clarify or provide new guidance on? 6.Should the HSE's guidance include examples of comparative costs of making first-aid provision? General public 7.Should first aid for the public be provided on a voluntary basis as at present, or should there be new legislation requiring employers to make provision? Training qualifications 8.Which of three options will help employers provide the most appropriate first-aid skills in the workplace: retention of the existing system; a minimum of one qualified first-aider for every workplace; or a system similar to the present one, but with shorter, more targeted training that is repeated at shorter intervals? Training standards 9.Should the current system of training standards continue? Currently, the HSE bases good practice on guidelines from the UK and European Resuscitation Councils (UKRC and ERC), the Voluntary Aid Societies (VASs - St John Ambulance, St Andrew's Ambulance Association and the British Red Cross) and other sound medical and scientific research. The three options for change are: restricting the standards to those of the UKRC and ERC; widening the bodies to include ambulance bodies and medical Royal Colleges; or encouraging the first-aid training industry to develop its own standard-setting body. 10.Which of the four options in question 9 is preferable? Training approval arrangements 11.What are the advantages and disadvantages of three options for approving training providers? Currently, the HSE approves training providers, an activity that it considers inconsistent with its core business. The HSE does not favour this option and suggests two alternatives. First, the HSE approves the structure and syllabus of the training, rather than the trainers, while a new monitoring body ensures standards are maintained. Second, in the longer term, the approval system could be scrapped, leaving employers to determine the adequacy of the training, assisted by HSE guidance. This would also mean that the training courses in table 1 would not be developed. 12.Is there a benefit in establishing a nationally agreed qualification and register for first aid at work trainers and assessors? 13.Does the HSE's guidance to training-providers need to be expanded, particularly if the HSE's involvement is reduced? First-aid boxes 14.Which of three options will help employers identify the most appropriate contents for a first-aid kit in their individual workplaces? The options are: no change from the current arrangements; replace the current HSE guidance; or amend the ACoP to specify a mandatory minimum list. 15.What advice can employers and others expect from the HSE on first-aid equipment? Medicines 16.Are there any circumstances in which first-aiders
should be responsible for the distribution of over-the-counter medicines
to employees? |
TABLE 1: THE PROPOSED FIRST-AIDER COURSES
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Emergency first-aid course |
First aid at work course |
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What to do in an emergency |
Emergency first aid (as course on left) |
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Cardiopulmonary resuscitation |
Provision of appropriate first aid to a casualty who has a broken bone, injured spine, a burn, injured eye or has been poisoned |
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First aid for the unconscious casualty |
Recognition of common major illnesses and provision of appropriate first aid |
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First aid for the wounded or bleeding |
Importance of personal hygiene in first-aid procedures |
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Six hours, over one day |
Use of first-aid equipment |
1"A review and evaluation of the effectiveness of the Health and Safety (First-Aid) Regulations 1981", DDE21, HSE Books or www.hse.gov.uk/consult/live.htm, free. Comments to Alistair Steele, HSE, tel: 020 7717 6688, email: firstaid.dd@hse.gsi.gov.uk, or online questionnaire: www.hse.gov.uk/firstaid/live.htm, deadline 30 November 2003.
2"Evaluation of the Health and Safety (First-Aid) Regulations 1981 and the ACoP and guidance", RR 069, ISBN 0 7176 2608 3, HSE Books, £25 or free at: www.hse.gov.uk/research/rrhtm/rr069.htm.
3Available from mark.woods@hse.gsi.gov.uk.
