Like all employers, GP practices have to fulfil their legal duty to ensure the health and safety at work of their staff, so far as is reasonably practicable. The law requires all employers to undertake a ‘suitable and sufficient risk assessment’ proportionate to the nature of the work. This is a legal obligation implemented in the last century and overrides any national guidance.
The UKHSA IPC guidance has previously acknowledged that it “does not supersede existing legislation or regulations across the UK”. Risk assessment should not be viewed as another imposition arising out of COVID-19 but as good practice to reduce risks of infections of staff or patients.
Current IPC guidance now states that ‘employers must ensure that COVID-19 is included in risk assessments for any health and care staff who come into contact with COVID-19 due to their work activity’. As set out in HSE guidance on risk assessments, this includes ‘health and social care workers caring for infected patients’.
The Government’s COVID-19 Response: Living with COVID-19 is inconsistent with this, as it states that “the health and safety requirement for every employer to explicitly consider COVID-19 in their risk assessments” was removed on 1 April 2022.
With this conflicting advice, a practice might be vulnerable if their risk assessment does not include COVID-19 whilst prevalence remains significant since the legal obligations under the Control of Substances Hazardous to Health Regulations persist and overrides any national guidance.
This guidance provides information about COVID-19 related risk assessment in general practice, including the professional and legal requirements. It is a step-by-step guide for GP employers and practice managers on how to undertake it.
A risk assessment must include consideration of the workplace, the worker and their tasks. It involves:
- an assessment of the risk (an estimate of the product of the likelihood of an exposure/event and the severity of its consequences)
- a determination of what is needed to mitigate the risk to an acceptable level
- a gap analysis to identify what areas still need to be addressed
- a conclusion of what must be done to reduce the risk to an acceptable level.
It may be necessary to also document:
- what should be done but cannot be done at all, or has to be done in a pragmatic and less than ideal way (e.g. - because of reasons beyond the employer's control)
- what residual actions are for the DHSC and others to do once employers are confident that they have done as much as they can.
We have produced separate guidance about what the risk assessment process for doctors involves.
Assessing the risks in your practice
The HSE (Health and Safety Executive) provides guidance on assessing risks but doesn’t specify how to lay out your risk assessment. The scenarios we present below are intended for risk assessments specifically in GP practices:
Clinical workforce in a clinical contact
For example, clinicians consulting and examining patients, doing BPs, ECGs, phlebotomy, or vaccinating in clinics:
- high risk - face-to-face consultation in small poorly ventilated room
- medium risk - face to face consultation in a large, well-ventilated room with CO2 <800ppm, vaccination clinic outdoors in a gazebo.
Non-clinical workers in a patient-facing role
For example, receptionists:
- medium risk - screen partition separating patients and staff with good, well- maintained ventilation; vents on either side of the partition
- high risk - no partition (or partition but without separate ventilation either side) and/or ventilation inadequate or uncertain.
Non-clinical workforce in a non-patient facing role
For example, secretaries:
- high risk - small, poorly-spaced, at maximum occupancy CO2 >800ppm
- medium risk - large, well-spaced, even at maximum occupancy CO2 <800ppm.
Any workers interacting with each other
For example, staff room and staff meetings:
- high risk - small, poorly-spaced, at maximum occupancy CO2 >800ppm
- low to medium risk - large, well-spaced, even at maximum occupancy CO2 <800ppm.
Patients interacting with staff
- medium risk - face-to-face consultation in small poorly ventilated room
- low risk - vaccination clinic outdoors in well ventilated and well-spaced gazebo CO2 <600ppm.
Patients in waiting areas
- medium risk - small, poorly-spaced, at maximum occupancy CO2 >800ppm
- low risk - large, well-spaced, even at maximum occupancy CO2 <800ppm.
This example of risk assessment for practices does not consider the prevalence of COVID-19 in the community. When completing your assessment, you should adapt the risk levels above to your practice and community circumstances. As advised by HSE, failure to tailor generic example assessments to the specific environment will not provide protection for employees and is unlikely to satisfy the law.
How to mitigate the risks
Following the assessment of the level of risk, the next step is to identify measures that reduce the risk of transmission of COVID-19.
One practical approach is based on the framework used in occupational hygiene to assess and control risks from hazards in the workplace. In the context of COVID-19, the model works as follows:
- source - the infected individual (patients and staff)
- pathway - how the infection is transmitted
- receptor - an individual at risk of becoming infected (patients and staff)
In general practice, the main sources of occupational exposure to COVID-19 are patients with acute symptoms, other patients and other workers.
These have to be considered separately, as the prevalence of COVID-19 will be higher in people who are acutely unwell.
Possible control measures in relation to these sources of infections include:
elimination of interactions - introducing virtual consultations and having certain staff working from home
reduction of interactions - undertaking as many consultations as possible remotely. This also applies to staff-to-staff interactions, consider video-conference meetings rather than face-to-face even when all participants are in the building. Risk is higher when masks/respirators are not worn, and it is important to minimise contact with others during breaks when staff eat and drink
triage and ‘cohorting’ - many patients are unaware of COVID-19 symptoms other than those publicised as such, or are reassured by a negative rapid antigen test (lateral flow), where these are available. Triaging would identify patients with COVID-19 symptoms and facilitate them being assessed remotely or in a dedicated area (from which more vulnerable staff may be restricted and in which a higher level of PPE may be required)
testing of patients and staff – when symptomatic, or screening when asymptomatic. This is especially important as the end of free testing for the general public (from 1 April 2022) is likely to have significantly reduced the number of people routinely testing using lateral flow tests.
Pathways of infection can be considered as:
- background exposures - in a waiting room/staff room
- near field exposures - face to face clinical assessment
Control measures include:
- limit the number of patients and staff in areas
- 'social distancing' of patients and staff with one-way systems
- ventilation and filtration, assuming the source and receptor (the employee) are far enough from each other. Chemical means like ozone and hypochlorite should not be used. Their benefit is not proven in controlling COVID-19 but their health hazards are well known.
- work practices - where possible staff who are undertaking non-patient-facing tasks should work as isolated from patients and colleagues as possible, maximising the use of space in the building.
Vaccination is an effective way to protect people against serious illness from COVID-19 although its effectiveness in reducing spread of the disease is limited. Being vaccinated is a professional responsibility. For example, GMC Good Medical Practice states that doctors "should be immunised against common serious communicable diseases (unless otherwise contraindicated)."
Providing information to staff about vaccination and encouraging uptake can be regarded as a control measure. Disparity in vaccination rates among different ethnic groups should be considered and barriers to vaccine uptake should be addressed.
Vaccination status should be considered when assessing the risks for susceptible practice employees. There are various tools to assess the susceptibility of individual staff members taking into account known risk factors and vaccination status, including COVID age.
Age and specific underlying conditions are associated with worse outcomes after infection. Evidence shows that people from a black, Asian and minority ethnic background and males may also be disproportionately affected by COVID-19. Risk assessments must consider ethnicity in combination with other risk factors and whether adjustments are required.
The terms 'vulnerable' and 'susceptible' are often used synonymously. In the context of occupational medicine, they can have a distinctively nuanced meaning, so the word susceptible has been preferred here.
The aim is to move, as far as is reasonably practicable, from high-risk to medium/low-risk level.
If environmental measures are not sufficient to reduce the risk to an acceptable level, further options are:
- restrict individuals who are more susceptible from the higher risk areas where they are most vulnerable to exposure
- use RPE such as FFP3 for employees in high-risk scenarios, and at least FFP2 for those in medium-risk scenarios.
It is accepted that risk cannot be eliminated, only reduced. You will need to review those mitigations that potentially reduce the standard of care, such as limiting face to face consultations, once the disease prevalence decreases.
* The proposed policy mandating NHS workers in England to be vaccinated against COVID-19 was dropped in January 2022 (this policy was never going to be applied to the other UK nations).
Completing your assessment
You should consult with your employees and their (safety) representatives, and clearly communicate your plans to them.
You should also be aware of other direct implications of the new working arrangements such as:
- the likelihood that risk mitigation arrangements combined with staff sickness absence may be causing lone working
- the psychosocial consequences of the pandemic on staff, like burnout.
The most recent guidance on IPC (infection prevention and control) published by the UK Health Security Agency does not supersede existing legislation or regulations across the UK:
- employers should consider the specific conditions of each individual place of work and comply with all applicable legislation and regulations, including the Health and Safety at Work etc. Act 1974
- the Management of Health and Safety at Work Regulations require employers with more than five employees to undertake regular risk assessments (every 1-2 years)
- the COSHH (Control of Substances Hazardous to Health Regulations) also apply to COVID-19 risks in healthcare workplaces.
- the 2020 Coronavirus Act and ensuing secondary legislation (health regulations), as well as official government COVID-19 guidance, have not provided derogation from the listed regulations.
Once a statutory risk assessment is undertaken in consultation with employees, as required by law, the ensuing measures are enforceable in the workplace. Employers could be entitled to impose necessary health and safety rules on employees without their consent.
The adjustments required for high-risk staff could have wide-ranging and significant impacts on individual practices, other staff and patients, particularly where it is a smaller practice, a rural practice or a practice with predominantly high-risk staff/doctors from Black, Asian and minority ethnic backgrounds.
Some mitigation arrangements may imply:
- a reduction in workforce and inactivity levels that could affect patient safety, increase stress on remaining clinicians and increase financial insecurity, eg through reduced QOF compliance
- that practices may be required to use locum support and/or increase their procurement of PPE at significant cost
- an increase in length of appointments may result when taking PPE on and off.
- that practices may have difficulty fulfilling training/mentoring requirements or providing usual levels of home visits.
The legal requirement to reduce risk to as low as reasonably practicable acknowledges that there is a balance between what could reduce risk and what is practicable. Guidance on this and other aspects of risk assessment can be found on the HSE website.
RPE (respiratory protective equipment)
There is overwhelming evidence of the exposure of healthcare workers to COVID-19 and the effectiveness of appropriate RPE in controlling this risk.
Different types of respirators relate to different levels of risk:
- FFP2 (filtering face piece 2)- high risk
- FFP3 (filtering face piece 3) - very high risk
They should be fit tested to ensure proper filtering. This is especially important for women and individuals of an ethic minority background who have been disproportionally affected by poorly fitting RPE. However, FFP3 respirators and fit testing are not readily available. HSE has carried out a review of FFP2 and FFP3 masks and confirmed that FFP2 respirators can be used in the absence of FFP3 respirators, once risks have been assessed.
If the risk in your practice is high or very high you should make, and document in writing, reasonable efforts to source FFPs with fit-testing. You can:
- ask your local commissioner using our template letter to CCGs
- contact your local hospital/NHS Trust/dentists
- contact commercial fit testing providers.
It is most unlikely that any degree of ventilation (even 12 Air Changes per Hour) or filtration will reduce the risk of face-to-face clinical interactions with an infectious patient to a degree as to cancel out the need for RPE. IPC guidance on PPE and RPE has changed throughout the pandemic and is often confusing and unhelpful. We recommend basing decisions about the appropriate level of RPE on local risk assessment as outlined in this guidance, in order to satisfy health and safety requirements and provide appropriate protection for staff and patients. Read the most recent government guidance on IPC (Infection Prevention and Control).
Note: Fluid resistant surgical masks (FRSM) or non-specific ‘face coverings’ have been shown to attenuate the risk of spreading COVID-19. However this reduction in risk is small when compared to respirators and they do not fulfil the standard or legal definition of 'Respiratory Protective Equipment'.