BAME risk assessment: NHS guide to assessing high-risk staff groups – 28 May

Risk assessments for staff

This page contains guidance for NHS organisations on how to enhance their existing risk assessments particularly for at-risk and vulnerable groups within their workforce. 

This includes workers returning to work for the NHS, and existing team members who are potentially more at risk due to their race and ethnicity, age, weight, underlying health condition, disability, or pregnancy. This guidance is applicable, with appropriate local adaptations, in all healthcare settings.  

Guidance produced by the Health and Safety Executive (HSE) will also help organisations identify who is at risk of harm. It includes templates and examples that organisations can adopt, along with specific guidance.

Additional guidance has been published relating to the need to assess and protect workers at greater risk if they contract COVID-19, and links are given at the end of this web page.  

A number of these organisations propose the application of risk scoring or stratification approaches and it should be stressed that these tools must be used with care. They help identify potential risks that need to be discussed further (normally with those with management responsibility) and support that discussion when it takes place. Such tools must not replace the compassionate and considerate discussion between those managing services and the worker. 

It is also important to stress and encourage any worker to seek guidance or support at any stage if they feel they need it – for example if they are feeling particularly anxious. Such discussions and reviews should be repeated regularly, particularly in light of the developing understanding of the virus and its impact.  

Context

Certain groups are more vulnerable to serious illness (and death) due to COVID-19. The evidence about these heightened risk factors is growing, and this guidance will be updated to reflect new evidence as it becomes available.

There has been a disproportionate impact of the virus on NHS workers from black and minority ethnic (BME) backgrounds. The risk assessment of those colleagues needs especially sensitive engagement given the systemic issues in every NHS organisation identified by the Workforce Race Equality Standard (WRES). These systemic issues and experiences of discrimination make it more difficult for BME colleagues to raise concerns and be heard within their organisations. 

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 to the organisation and their expertise and insights should be used in constructing local approaches to risk assessment. 
• 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 invaluable 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: 

• Occupational health
• Supporting vulnerable staff
• Staff returning to work
• Workforce supply and deployment
• Enabling staff movement

Undertaking risk assessment 

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 their 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 and trade unions regarding the approach to be taken to risk assessment and agreeing 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 with their manager any concerns as a result of the risk assessment guide or any concern or anxiety they might have (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.

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.    

Organisations working together in the south east have prepared two helpful resources which may assist those managing services and team members to have the purposeful and supportive conversations recommended by this guidance:

Wellbeing coaching questions – for managers

121 wellbeing check-in template – for staff

Where there are disagreements about the conclusions reached between those line managing services and staff, locally agreed grievance resolution processes will of course apply.

Vulnerable workers 

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. 

These factors are expanded upon in the risk reduction framework paper published by the Faculty of Occupational Medicine and summarised in this diagram.

Black and minority ethic staff

Emerging evidence shows that black and minority ethnic (BME) communities are disproportionately affected by COVID-19. 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.  

Pregnancy

Pregnant women at whatever stage of pregnancy are classed as at-risk. The Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and Faculty of Occupational Medicine have developed specific guidance for healthcare workers who are pregnant.  In addition, staff who are returning from maternity leave should be assessed against government advice. 

Age

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. 

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.  

Weight

There is emerging evidence to suggest that one of the risk factors for becoming seriously unwell with coronavirus 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. 

Disability

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.

Gender

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:

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.

NHS England and NHS Improvement is also providing NHS workers with free access to psychological and practical support.  

A free wellbeing support helpline 0300 131 7000 available from 7am to 11pm seven days a week, providing confidential listening from trained professionals.

A 24/7 text alternative to the above helpline – simply text FRONTLINE to 85258.  An online portal with peer-to-peer, team and personal resilience support.

A free bereavement and trauma support line for Filipino colleagues – call 0300 3031115 available seven days a week between 8.00am and 8.00pm. This service is provided by Hospice UK.

Ongoing actions

Leadership teams should keep their workplace and workforce risk assessments updated and 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:

• 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.
• 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.

Board assurance

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.

Other resources:

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. 

• Wellbeing coaching questions – for managers This set of questions will help managers start conversations with staff about undertaking a risk assessment and build insight into how a staff member is feeling.
• 121 wellbeing check-in template – for staff  This template aims to help staff to collate their thoughts and feelings ahead of a discussion with their manager. 

FOM: Risk reduction framework 

An independent group of clinical academics and other doctors, led by Professor Kamlesh Khunti from Leicester University, has reviewed the present evidence regarding the impact of COVID-19 on BME communities.  Now published on the FOM website, view the BAME specific risk reduction paper.

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

This is expected to be published in June.

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. Read the guidance in full. 

NHS trust examples

These documents are being regularly updated by the organisations and should be used in conjunction with national Covid-19 advice. 

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:

• A risk assessment matrix – this document provides an overview of the steps required to successfully complete a risk assessment for BME, vulnerable and pregnant staff groups. 
• Guidance for line managers on COVID-19 risk assessments, including answers to frequently asked questions.
• Dedicated guidance for line managers in supporting BME staff with COVID-19 risk assessments.
• Occupational health advice for staff – this document outlines guidance for isolating staff who have COVID-19, as well as guidance for pregnant, vulnerable, and very high-risk staff groups, including BME staff.
• Staff FAQs – occupational health guidance for staff based on frequently asked questions relating to Covid-19. 

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.

Source: NHS Employers, Risk assessment for staff [published 28 May]