Certain groups are more vulnerable to serious illness (and death) due to COVID-19. Employers have a duty of care by law to protect their staff from harm, injury and illness, and must employ risk scoring, stratifications and individual assessments to assess the level of risk to their workforce.
NHS organisations must continue to prioritise risk assurance conversations with all at-risk staff, particularly as we are in darker winter months and with rising cases of COVID-19. The ask, which has come from NHS England and NHS Improvement’s (NHSEI) senior leaders, highlights the importance of ongoing risk assessments which was first emphasised in April 2020.
This page contains guidance for NHS organisations on how to enhance their existing risk assessments particularly for at-risk and clinically extremely vulnerable groups within their workforce during COVID-19. This guidance is applicable, with appropriate local adaptations, in all healthcare settings.
Implementing risk assessments
Support and advice
It will undoubtedly be necessary to supplement individual discussions with workers with the established collective representation processes in place within organisations. This will help organisations understand areas of concern for their teams, identify where colleagues may be finding it hard to speak up as individuals, and could include:
- Trade union colleagues and local partnership forums are an invaluable source of support and their expertise and insights should be used in constructing local approaches to risk assessment. Employers can access a summary of principles from NHS trade unions on health and safety risk assessment and vulnerable workers (including BME staff groups) during COVID-19.
- Other networks, such as those for black and minority ethnic (BME) or disabled staff, will also be an important area of support and insight to organisations.
- Occupational health teams, chaplains, and freedom to speak up guardians are good sources of advice and insight.
- Advisory functions (where available) including HR, infection prevention and control, health and safety, and governance.
In terms of deploying workers returning to healthcare settings, risks should be assessed at the occupational health screening stage and deployment decisions should take account of this.
Public Health England (PHE) has published guidance on testing and personal protective equipment (PPE) and this should be followed as part of the design of infection prevention and control compliant safe systems of work.
There are specific sections in this COVID-19 guidance which are useful cross-reference points for those responsible for risk assessment:
Undertaking risk assessments
It is recommended that employers undertake the following steps, in addition to targeted discussions with staff representatives and workers in higher risk areas.
- Reflect on the intelligence available regarding the organisation. This would include data on absence due to COVID-19, any worker deaths due to COVID-19, staff survey data, WRES and WDES data, and any pulse survey data.
- Consult with staff networks, trade unions and other key stakeholders for support and advice regarding the approach to be taken to risk assessment and agree how a continued dialogue can be maintained.
- Communicate to all workers, whatever their professional background or work area, describing the approach being taken to risk assessment, reassuring them as to the nature of the assessment being undertaken and the support available to them. The organisation’s policy regarding confidentiality should be clearly stated (and complied with).
- Share the agreed local risk assessment tool or guidance with all team members to help them identify whether they are in an at-risk group.
- Explain the need for staff to discuss any concerns as a result of the risk assessment guide or any concern or anxiety they might have with their manager (and offer them alternative routes of support prior to these discussions).
- Agree alternative routes through which individuals might raise concerns or flag the need for a risk assessment discussion.
- Provide guidance to those managing services regarding the follow-up conversations about risk with their team members, including the potential responses to protect or support staff.
- Review and repeat risk assessments as necessary in line with individual circumstances, emerging evidence, and/or national guidance. Government advice on vulnerable workers and vulnerable workers and shielding should be followed and every effort made to encourage all staff to disclose any medical condition that might compromise their health. For existing staff, undertaking a risk assessment will enable mitigating factors and additional support to be explored.
Risk assessment conversations
Organisations should regularly talk to staff through one-to-one conversations about how they are and whether they need any support to improve their working experience. Risk assessment discussions should be purposeful, supportive and specifically designed to review physical and psychological risk factors to an individual, as well as their personal circumstances.
Employers can access tools and resources which may assist those managing services and team members to have the purposeful and supportive risk assessment conversations recommended by this guidance. This includes Wellbeing coaching questions for managers to help start conversations with staff about their feelings on undertaking a risk assessment and a 121 wellbeing check-in template, which aims to help staff collate their thoughts and feelings ahead of a discussion with their manager.
Employers will need to take into account government advice on vulnerable workers and shielding. All staff should be encouraged to disclose any medical condition that might compromise their health. There may be particular concerns regarding discussion by those managing services with their team members regarding health conditions which would normally only be discussed with the worker’s primary care practitioner or an occupational health advisor. Dr Steve Boorman, chair of the ethics committee of the Faculty of Occupational Medicine, has clarified that:
‘Both the employer, through line managers, and the employee have a duty of care – to protect themselves, and their patients, ie the public, from harm. The health status of the employee is important to this. It would not be considered unethical to ask that the relevant part of personal clinical information is shared. If practically speaking this cannot be done via occupational health, because of the volume of work and other priorities, then, subject to line mangers being cautioned about sensitivity and confidentiality, this enquiry, by managers, would not be unreasonable.’
Notwithstanding this advice, organisations will recognise that some team members will have health concerns that they may not wish to discuss with their manager. In this situation, a review by the organisation’s occupational health team or another relevant person may be appropriate.
Where there are disagreements about the conclusions reached between those line managing services and staff, locally agreed grievance resolution processes will of course apply.
Tools and resources:
There are a range of evidence-based risk assessment frameworks, matrices and tools available, developed by professional bodies, NHS organisations and clinicians.
The tools and resources outlined below have been developed over the course of the pandemic using the emerging evidence, however, there is no single professional consensus or agreed approach. Therefore, this section signposts to a range of tools and resources to support employers to develop local approaches to risk assessment.
Organisations should consider the guidance outlined here along with the full range of risk assessment frameworks, matrices and tools, and work with their occupational health department to develop and review organisational approaches to risk assessment.
Tools to support health and wellbeing conversations
Based on the work of healthcare organisations in the south east region, these two documents provide advice on holding health and wellbeing, and risk assessment discussions. Both documents are editable so trusts can add their logos and personalise the content.
FOM: Risk reduction framework
The risk reduction framework paper was developed by an independent group of clinical academics and other doctors, led by Professor Kamlesh Khunti from Leicester University. The risk reduction framework was published by the Faculty of Occupational Medicine (FOM) in May 2020 and highlights that increasing age, BME ethnicity, male gender, underlying health conditions and pregnancy have the potential to increase an individual’s risk from COVID-19. The paper suggests that risk assessments should be prioritised for staff in these groups.
The British Association of Physicians of Indian Origin
The British Association of Physicians of Indian Origin (BAPIO) has developed a risk stratification tool, which informed the approach now being adopted by NHS Wales.
Joint staff side guidance
NHS trade unions have published a summary of principles on health and safety risk assessment and vulnerable workers (including BME staff groups) during COVID-19.This includes principles relating to prevention measures, access to risk assessment, risk assessment process, and risk reduction measures.Tips and signposting to resources for both safety reps and staff side are included in the guidance.
Royal College of Psychiatrists
The Royal College of Psychiatrists has published guidance on the assessment and management of risk for BME staff in mental healthcare settings.
NHS England and NHS Improvement: Risk assessments and beyond
NHS England and NHS Improvement has developed guidance for NHS workforce leaders across sustainability and transformation partnerships (STPs) and integrated care systems (ICSs) on enhancing risk assessments and supporting staff beyond the risk assessment.
NHS England and NHS Improvement has also collated a series of risk assessment examples from primary and secondary care, as well as, examples of effective education and infection control approaches.
ALAMA Covid-Age Tool
The Covid-Age tool was developed by the Association of Local Authority Medical Advisers (ALAMA), a group of occupational physicians, clinicians and academics.The tool examines personal clinical risk factors and calculates an individual’s 'Covid-Age' as a way of quantifying risk. It is intended for use as part of an occupational health assessment of fitness for work. Assessment of work-related risks in relation to COVID-19 remains complicated. Personal or ‘clinical’ risk factors are one element in considering the reduction of risks for those working in healthcare or elsewhere.The knowledge of personal risk factors is still evolving as the pandemic continues and more is understood, but this tool is based on emerging evidence and will be continually reviewed and updated.
The Covid-Age tool alone does not replace the need for other elements of risk assessment and control advice.The tool could be used to support risk assessment conversations with line managers and, where clinical risks are identified, occupational health advice should be sought.
Who should be risk assessed?
Organisations should consider the following issues in relation to people in their workforce who are at higher risk if they contract COVID-19. These issues, where identified, should always be discussed between those managing services and individual workers, who will take advice from occupational health and HR colleagues where necessary.
Employers will need to take into account government advice on vulnerable workers and shielding. All new staff should be encouraged to disclose any medical condition that might compromise their health.
The evidence about heightened risk factors to COVID-19 is growing, and this guidance will be updated to reflect new evidence as it becomes available.
Black and minority ethnic staff
Emerging evidence shows that black and minority ethnic (BME) communities are disproportionately affected by COVID-19, particularly those with comorbidities who are presenting adverse outcomes at a younger age. The reasons for this are not yet fully understood, but the health inequalities present for BME communities have long been recognised.
Within the NHS 40 per cent of doctors and 20 per cent of nurses are from BME backgrounds, as are substantial numbers of health care support workers and ancillary staff.
Organisations should ensure that line managers are supported to have sensitive and comprehensive conversations with their BME staff, recognising the long-standing context of the poorer experience of BME in all parts of the NHS. They should identify any existing underlying health conditions that may increase the risks for them in undertaking their frontline roles, in any capacity. Most importantly, the conversations should also, on an ongoing basis, consider the feelings of BME colleagues, particularly regarding both their physical safety, their psychological safety, and their mental health.
Pregnant women at whatever stage of pregnancy are classed as at-risk and a risk assessment/risk assurance conversation is to be carried out. Information contained in the Royal College of Obstetricians and Gynaecologists (RCOG)/Royal College of Midwives guidance on coronavirus (COVID-19) in pregnancy should be used as the basis for a risk assessment.
The RCOG, Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Public Health Scotland have developed guidance for healthcare professionals on coronavirus (COVID-19) infection in pregnancy.
The Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and Faculty of Occupational Medicine Occupational health advice for employers and pregnant women during the COVID-19 pandemic has now been archived as a single recommendation is no longer appropriate. Please read the RCOG, RCM and FOM joint statement on Occupational health advice for employers and pregnant women.
In addition, staff who are returning from maternity leave should be assessed against government advice.
There is evidence that COVID-19 has a greater impact in older age groups. Therefore, older staff may be more at risk as a result of increased age and likelihood of long-term conditions. Employers will need to consider this and take into account government advice on vulnerable workers and shielding. All new staff should be encouraged to disclose any medical condition that might compromise their health. Although the risks of severe COVID-19 increases with age, it should be noted adverse outcomes relating to COVID-19 occur at an earlier age in BME populations. Employers should consider the intersectionality of age groups in staff when carrying out risk assessments.
Underlying health conditions
In supporting workers with underlying health conditions, please see our section on supporting vulnerable staff for further guidance on those classified at being at higher risk, those at increased risk due to complex health problems, and those with underlying health conditions. For these staff, undertaking a risk assessment will enable appropriate support and steps to be taken.
There is emerging evidence to suggest that one of the risk factors for becoming seriously unwell with COVID-19 is being obese. Some people, such as people of Asian family origin and older people, have comorbidity risk factors that are of concern at different BMIs. Occupational health advice might be required when considering risk factors in these groups, even in people not classified as overweight or obese.
As this is a developing pandemic and research is ongoing evidence is still evolving and therefore this guidance will be updated as this develops. It is helpful for employers to ensure those managing services are aware of this emerging area for them to be prepared to have sensitive conversations with staff where this is identified as a risk factor and anxieties exist.
In line with agreed policies and legal protections, disabled staff working across the NHS are likely to manage their disability through the application of reasonable adjustments. Some of these adjustments will be formally agreed and some informally adopted by staff to suit their own circumstances. It is possible that the current situation of the COVID-19 pandemic could bring further challenges for some staff with disabilities in terms of amending / altering any reasonable adjustments – and this should be assessed and explored as part of any risk assessment process.
Some disabled staff members may have a weakened immune system, leaving them more vulnerable to getting an infection. There may be issues associated with personal protective equipment (PPE) and those with a mental health condition may feel increased levels of anxiety and stress.
Government advice on vulnerable workers and shielding should be followed and every effort made to encourage all staff to disclose any medical condition that might compromise their health. For existing staff, undertaking a risk assessment will enable mitigating factors and additional support to be explored.
There is some emerging evidence to suggest that COVID-19 may impact more on men than women, so employers may need to review the approach they have taken in relation to risk assessment in light of this.
Religion or belief
The COVID-19 situation may coincide with specific religious events – some of which may require staff to fast. This may have an impact on the ability of individual members of staff to perform their role fully, especially when wearing the highest levels of PPE. Those managing services should have a thorough and comprehensive conversation with individual staff about how they will cope in these circumstances and consider what adjustments could be made.
Employers should also consider the need for staff generally to be able to take time to conduct spiritual/religious reflection away from the frontline.
Outputs and actions
Organisations should gather the relevant information as outlined above, through one-to-one conversations with their teams. Those managing services should listen carefully to concerns and provide support and consider adjustments or redeployment for any staff who are identified as being at greater risk. Adjustments may include:
1. Limiting duration of close interaction with the patient (for example, preparing everything in advance away from them).
2. If possible, maintaining a two-metre distance from the patient.
3. Avoiding public transport/ rush hour through adjustments to work hours.
4. Asking patients to wear a mask for staff member interaction.
5. Asking that only the patient is in attendance for home visits/ outreach where possible.
6. Providing surgical masks for staff members for all interactions with patients or specimens.
7. Redeploying staff to a lower risk area.
8. Advising staff to leave the area for 20 minutes when AGP is undertaken on suspected/ confirmed COVID patient.
9. Encouraging remote working.
10. Varying work patterns.
Additional support through employee assistance programmes, occupational health or chaplaincy teams may also be appropriate. Managers should seek and follow occupational health advice where appropriate.
Employers can enhance local approaches by signposting to a range of national health and support available to NHS staff during COVID-19 being provided by NHS England and NHS Improvement.
Leadership teams should keep their workplace and workforce risk assessments up to date as part of a continuous process in keeping our staff safe. Employers should ensure managers engage and communicate regularly with workers identified as being at higher risk. Risk assessments should be repeated where new information becomes available or where an individual requests a review. Organisations should also continue to consider any updates to national or local guidance regarding the testing of staff.
The following steps can also be taken to ensure ongoing review of the deployment of staff from higher risk groups:
Contacting staff in at-risk categories to ensure they are reassured and that any mitigating steps from existing risk assessment processes have been enacted.
- Consultation and dialogue with trade union representatives through local partnership forums, including health and safety representatives.
- Ongoing engagement with relevant staff networks to ensure that there is an ongoing awareness of any concerns, questions and advice, and they are fully informed of any escalation plans and any potential for redeployment – early and regular communication with all staff groups is crucial.
- Advice from the freedom to speak up guardian to ensure that colleagues from higher-risk groups can candidly raise any concerns about the application of the risk assessment process.
- Assessment of data about the local incidence of COVID-19, particularly as more information becomes available through greater access to testing.
Where applicable, an organisation’s board should consider the effectiveness of the deployment of their risk assessment policy but also importantly the context within which that policy is being deployed. Executive leads (that is those directors accountable for infection prevention and control, health and wellbeing, and equality and diversity) should provide evidence to the board (or relevant board committees) of:
- engagement with staff and their representatives
- advice of the freedom to speak up guardian regarding risk assessment
- revised policies and approaches
- advice and guidance to managers
- the proportion of staff who have identified as high-risk
- analysis of the response to the identification of risk
- other relevant data
- revisions to the organisational WDES and WRES action plan.
The chief nursing officer has issued guidance on board assurance regarding infection prevention and control.
Boards may also want to consider hearing directly from the chairs of their staff side, staff networks and their most senior occupational health advisor regarding the effectiveness of the risk assessment approach within their own organisation.
NHS trust examples
These documents are being regularly updated by the organisations and should be used in conjunction with national COVID-19 advice.
Barts Health NHS Trust
The trust developed a digital risk assessment system, working with external partners to develop bespoke software. The digital system is integrated with the organisation’s digital learning platform, a system all staff already access for mandatory and statutory training, and can be used on a mobile, tablet or laptop. Staff are able to complete a self-assessment, line managers can review the assessment in conjunction with staff and the HR team can review or escalate cases depending on the outputs. This system enables the trust to monitor data in real-time and pulls through into board reporting. The trust are constantly reviewing the digital form in response to changes in national and local guidance. You can watch a demonstration of the system or contact Harjinder Mann, digital systems lead at Barts Health, on email@example.com to find out more.
Calderdale and Huddersfield NHS Foundation Trust
The trust took an evidence-based approach to inform its risk assessment process, by analysing local workforce and clinical data. Based on evidence and consultation with trade unions and its local BME network, it was decided the risk assessment process should be implemented for all staff.
The trust’s comprehensive approach to risk assessment focuses not only on physical health risks, but also considers mental health and personal circumstances. To support line managers and staff members in having robust and meaningful conversations, a suite of tools and guidance documents were developed:
- Risk assessment template – this document asks staff members a number of questions to identify physical risks, mental health concerns and personal circumstances.
- Risk assessment process – outlines the steps which take place following each individual completing the risk assessment template. Where clinical or physical risks are identified, occupational health undertake a clinical assessment of risks.
- Staff guide for risk assessments – to inform staff about the risk assessment process.
- Manager guide for risk assessments – to support managers to have conversations with their staff members and outlines what managers need to do to support risk assessments and reasonable adjustments.
Guys and St Thomas’ NHS Foundation Trust
As part of the trust’s COVID-19 response, Guys and St Thomas’ has developed and implemented a robust approach to carrying out risk assessments for their staff, including:
Norfolk and Norwich University Hospitals NHS Foundation Trust
To support individuals and line managers to undertake risk assessments, the trust developed a risk assessment matrix. The matrix is designed to consider individual risk factors, including health conditions, as well as race, age, and pregnancy. The trust is using this matrix to encourage all staff and line managers to consider their individual risks and to work with their occupational health team to undertake a full risk assessment where this is indicated.
NHS Wolverhampton Clinical Commissioning Group
Wolverhampton CCG and Public Health Wolverhampton along with The Royal Wolverhampton NHS trust have worked together to develop a system-wide tool that supports individuals and line managers to undertake risk assessments during COVID-19. It's unique in that it considers an employee's risk factors in relation to their workplace risk factors. This allows for appropriate risk mitigation based on individual circumstances and can be used in both NHS and non-NHS settings. They also worked together to develop an individual's risk assessment proforma, which allows employers to keep a record of the staff member's COVID-19 risk assessment, as well as, a dedicated risk assessment form for those staff who are shielding and women over 28 weeks pregnant.