Managing the hidden killer

Asbestos in healthcare is not a new issue. For as long as asbestos has been identified as a problem, money has been spent on removing it or remediating it in hospitals and other healthcare premises.
    
A lot of healthcare premises are quite old. Although new hospitals are being built, the image of the Victorian Infirmary is not too far removed from most people’s memories. Large boiler houses, steam mains, subways – all packed with asbestos – are realities from not too long ago. Hospitals with entrances to roof voids or doors to underground ducts which have a padlock and a non-specific “No entry” sign are still out there. What is beyond those signs is almost certainly asbestos.
    
From the patient’s viewpoint, however, these very large asbestos installations were not really likely to affect their health. Although hospital maintenance workers have undeniably suffered substantial exposure and died as a result, and more will suffer as a result in the future, this largely did not impinge upon the patients and medical staff. Other asbestos did and still does.
    
Asbestos installations in hospital wards and public areas may be in bad condition; what if it needs attention? That means loss of bed-days. Hospital targets for treatment are the stuff that the NHS runs on. Can you imagine the headline in the local paper to the effect that operations have been cancelled at the local hospital because the Health & Safety Executive has closed the hospital because of the state of the asbestos? It will never happen – but in some hospitals perhaps it should.

Cheap specifications
Think about your local doctors’ surgery or health centre. A lot of readers’ doctors will have a surgery built between 1947, the start of the NHS and the 1980s. These buildings were built to cheap specifications and most likely were built with asbestos. In a great many cases that asbestos is still where it was installed. If you attend your local healthcare facility and find it run-down and in need of overhaul, there is a good likelihood of there being asbestos containing materials in need of attention.
    
The good news in this is that most of us spend only a short period of time in these buildings, unlike the equally run down education buildings where our children spend a great deal of time and as a consequence may breathe a lot more asbestos.
    
Hospitals are places where a lot of very poor asbestos removal work has been undertaken in the past, resulting in people relying upon inadequate cleaning and being exposed as a result. Contractors were hired at unsustainably low prices and work was undertaken in appalling conditions on hot, live heating pipework and boilers because the hospital was not prepared to close parts so that work could be undertaken properly and safely. The contractors did the best they could, but the standards of cleaning were in many cases woefully inadequate.
    
Across the country the picture does vary, however, the history of NHS Trusts changing names and hospitals changing their relationships with other hospitals has led to lack of consistency in the long term approach to asbestos.
    
Not all healthcare buildings have a substantial asbestos problem. For those premises of traditional construction, built up to and after World War II, the asbestos was often confined to substantial heating systems that have generally been dealt with because of the failings of the aged plant that has needed replacement. However, please do not take this to mean that a traditionally built old hospital is asbestos-free. All those years of modifications and renewals may well have imported asbestos containing materials.
    
Between 1947 and the early 1980s a lot of healthcare premises were built, to varying specifications. The amounts of asbestos incorporated into the structures varied; at worst structures were of steel, wood and asbestos with little else.
    
Healthcare premises built from the mid-1980s onwards should contain only lower risk asbestos containing materials and any built after 1999 should have none. The real problem is that nobody, including HM Government, actually knows what the overall picture is.

Duty to manage
Since 2004 the law has required that asbestos in healthcare premises, together with all non-domestic properties, should be managed. This management is intended to ensure those that occupy the buildings are not exposed to asbestos and those that work upon the fabric of the building are informed about the asbestos that is present, so that they can avoid it.
    
The law requires that there be a Duty Holder. In hospitals this is normally the delegated responsibility of the Estates Department, who do their best to work around the demands of the management and medical staff. In Primary Care Trusts, arrangements tend to be less organised and good examples of asbestos management are harder to find.
    
Whilst the ’old days‘ of Health Authorities may not have suited certain operational efficiencies the chances of the old system managing asbestos was a lot greater than current regimes. It should be noted that non-compliance is a criminal not civil offence and could potentially result in a prison sentence. To spell this out:

• If the patients or staff are being exposed to asbestos dust whilst in the healthcare premises, it is the chief executive’s fault.
• If a workman, unknowingly disturbs asbestos in a healthcare premises, it is the chief executive’s fault.

Fortunately for chief executives, the number of times that prosecution has been directed at healthcare is very small indeed. The number of times that asbestos incidents have occurred that could possibly have been directed at the chief executive is quite large.

What does the Duty Holder need to do?
The first thing that is needed is an up to date asbestos survey in order to determine what asbestos is present the premises. You may see references to the term Asbestos Register, which is no more than a list of asbestos items present and is fit for purpose. Of course if you are lucky enough to have a healthcare building built after 1999 you can presume no asbestos and not bother to read the rest of this article! The legal requirement is not to have a survey, but to manage the asbestos, but unless you know where it is you cannot manage it.
    
If you do not have an asbestos survey, go to your NHS Trust and seek advice. Many have arrangements with UKAS Accredited Inspection Bodies for asbestos surveying and even if you have to pay for it, at least they should ensure you obtain a quality product at a reasonable price. Failing that go to an organisation called Asbestos Testing & Consultancy (ATaC) www.atac.org.uk and look for a member in your area. Once you have an asbestos survey or register, you need to understand the implications of it, if you are to properly manage the asbestos in your premises.

Regulations and compliance
The regulations in question are the Control of Asbestos Regulations 2006 (CAR 2006). CAR 2006 prescribes three categories of training – asbestos awareness training, non-licensed asbestos training, and licensed asbestos training.
    
Asbestos Awareness training is a requirement for anyone that works on the fabric of a building, but with no intention of working with asbestos. Such training typically takes half a day. The Duty Holder should ensure that everybody – contractor, site manager etc – that works on the fabric of the building, or sends people to do such work, should have undertaken such training. It is also suitable for the Duty Holder to help in understanding the asbestos survey. Many managers send their maintenance staff for such training but ideally they should go themselves as well.
    
Non-licensed training is for anybody that works on low risk asbestos containing materials. This is a requirement for contractors and some site managers, dependent upon what they are required to do. The scope of such work should be explained in asbestos awareness training.
    
Licensed asbestos training is only relevant to those you employ to undertake licensed work.

Practical duties
With a survey and a half day’s asbestos awareness training in place, you are prepared to manage your asbestos, although further training is desirable if you have substantial problems. If remediation or removal is indicated you need advice and likely sources of that are mentioned above. After that, what must you do?
    
Prepare a Management Plan, as to how you will manage your asbestos. No need for a huge document; a straightforward statement of what is to be done and who will do it, highlighting problem areas if any.
    
Ensure that whenever a person attends at your premises to work on the fabric of the building, they are shown the asbestos survey/register. If you are using suitably trained contractors, they should ask for it anyway.
    
At least annually, have someone inspect the condition of your asbestos containing materials, record the inspections and respond to deterioration. If you have any asbestos that is of particular concern inspect it more frequently.
    
Make sure your survey is kept up to date by recording any removals or remediation that has gone on, otherwise in five years time the survey will be distrusted and worthless.

Is this all worthwhile?
It is extremely worthwhile. Every site manager is very wary of harm coming to the public whilst on the premises. The trouble with asbestos is that the symptoms of this harm will not appear whilst the public is on the premises. It is not the public who are most at risk, it is the people that do work upon the building that need to be of most concern. HSE has already run campaigns highlighting the dangers to tradesmen and another campaign is due in the autumn. The thrust of the campaign is directed at the tradesmen; they should ask “Where is your asbestos?” before they commence work. If they do not get a satisfactory answer they should leave the building.
    
Mesothelioma is a cancer linked to asbestos exposure. In education, according to the HSE, 183 teachers and lecturers died from mesothelioma between 1980 and 2000. Between 2002 and 2005 the cancer killed 76. Direct comparison of the Proportional Mortality Ratio, which is a figure that makes allowance for numbers in the professions, between female teachers and female nurses, reveals that mesothelioma deaths in female nurses are half that of female teachers, though still higher than the expectation for females with no asbestos exposure.
    
There may be differences in the career paths of the two professions in that female teachers only work inside schools whereas some nurses work in the community. There are significant differences in the occupation of the buildings, as asbestos dust becomes airborne when asbestos is disturbed. When a school or hospital is empty there is no measurable asbestos in the air. When doors are slammed, wind causes asbestos ceiling tiles to ripple in their grid, school bags knock corners off asbestos panels, asbestos dust becomes airborne and the potential for future harm is released. Asbestos in healthcare premises is clearly much less likely to suffer in the same way.
    
Almost 25 per cent of Mesothelioma deaths cannot be traced back to a known source of exposure; asbestos exposure is accumulative. Once breathed in the tiny fibres will last your lifetime; you will die with them, or if you are unlucky you will die from them. Any means of reducing the lifetime exposure to asbestos will reduce the future human statistics.
    
A great deal of money would be needed to rid all healthcare premises of asbestos, but good management can improve the situation. Management will not work without knowledge. Investment of a small amount of time and money with a UKATA member to learn something about asbestos could have great benefits for the future.

For more information
Information about asbestos is readily available from the Health & Safety Executive (HSE) www.hse.gov.uk/asbestos

The UK Asbestos Training Association (UKATA) www.ukata.org.uk is set up with the aim of setting standards in asbestos training and monitoring its members’ competency and performance.