Alison Leary: Why does healthcare reject the precautionary principle?

Calls for covid-19 to be an occupational disease have been made, but little action has been taken, says Alison Leary

Having worked in safety critical industries for many years there are things that really stick in my mind. I spent some time with a retired engineer called Allan Macdonald who worked on the space shuttle Challenger in the 1980s. The Challenger exploded on launch, killing seven astronauts. The disaster was not only a tragedy, but a cultural shift for NASA. The political pressures to launch Challenger overrode safety concerns. But Allan MacDonald’s words stuck with me. “Suddenly it was about proving launching would be dangerous, in the past we had to prove things were safe.” In the pressure of politics, NASA effectively abandoned the precautionary principle.  

The precautionary principle is important in high risk, high harm, safety critical work. Risks to workers, customers, or service users are substantial, and so the precautionary principle in which precautions are taken until safety is proven, often apply. This is often because there are not large-scale randomised control trials of safety interventions. Pragmatism and a measured approach to risk often apply. A lot of safety is either tombstone legislation or precautionary. 

In healthcare it’s different. Healthcare takes the 1980s Reagan era NASA approach, i.e. the status quo applies until something is proven dangerous and harmful. The burden of proof is often high and often falls to the workforce to “prove.” We have seen this with issues such as safe staffing. Despite the evidence suggesting a robust relationship between staffing and the safety of patients and the workforce, it’s still up to the workforce to prove the risk rather than policy makers heeding the evidence and erring on the side of caution.

This has been brought into sharp focus recently during the pandemic and the use of personal protective equipment (PPE) for healthcare workers. 

The start of the pandemic saw a workforce underserved with poor access to PPE. Colleagues in the NHS reported wearing bin liners, ski goggles, or other homemade solutions. Those in social care reported extremely poor access. During the pandemic the risk to workers in frontline jobs has been ever present. Calls for covid-19 to be an occupational disease have been made, but little action has been taken. As far back as July last year, Amnesty International reported that England and Wales had the highest rate of healthcare worker deaths from covid-19, with workers from Black and ethnic minority groups over represented. 

The Royal College of Nursing have just published a report by Dinah Gould and Edward Purssell, two independent experts, calling for changes to the guidance on PPE in the workplace. They argue that the previously issued guidance from Public Health England is now outdated and does not provide adequate protection. The report analysed a literature review which underpins the current guidance. They found that the review met just four of the 18 criteria that the experts deemed essential. Crucially, the report found that the review failed to fundamentally consider how covid-19 is transmitted—airborne infection—about which growing evidence has emerged during the pandemic.  

Effectively this would mean employers should be offering a higher level or protection to workers in health and social care exposed to known or potential covid. Erring on the side of caution might seem the logical thing to do and indeed some employers are offering higher levels of protection to staff. However the healthcare arm’s length bodies are not budging. The requests fall on deaf ears and it is up to individual employers to decide what they will provide. 

This is an issue as not only does it mean employees might not be getting the protection they need, but also one of the fundamental principles of safety are rejected. Given that healthcare is a high risk, high harm potential activity this seems short sighted. 

Allan Macdonald died this week. His experience of the shift from precautionary to risky was something he often spoke out about. In healthcare we fail to heed the precautionary principle for many different reasons, but potentially the cost of doing so is high and ultimately catastrophic. 

Alison Leary is a professor of healthcare and workforce modelling at London South Bank University @alisonleary1

Competing interests: none declared.