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The Casella Report

Date: 16 Sep 2003

Back in October 2001, Research into the effectiveness of Health and Safety (First Aid) Regulations 1981 was commissioned by the HSE. The report, produced by Casella Winton, was published on the 30 January 2003.The HSE is considering the recommendations made in the research report and is aiming to issue a Discussion Document in Autumn 2003.

For those of use who are not that keen to wade through all 93 pages, here are a few of the points that you may find of interest.

Relevant recommendations made in the report, worth noting

  • To achieve greater proportionality to the assessed risk, the introduction of a more basic first aid level to that of the full current first aider is recommended.
  • The use of HSE approved trainers for Appointed Person and Basic Level (above) courses.
  • To address 'Skill-Fade' by increasing the frequency and duration of additional training (The report further states that this should be the subject of review and should not seek to increase the cost burden on employers significantly).
  • Improve the current guidance, specifically the Approved Code of Practice.
  • Improve guidance in the application of the regulations to companies with less than 5 employees and ‘small' companies.

Employers Survey Results

  • 29% of survey contacts did not think that FAW applied to their company or organisation. Almost all the companies who did not think the regulations applied to them were very small companies with less than 5 employees.
  • 78% said that they had referred to the ACOP when assessing first aid requirements for their companies and 82% thought that HSE guidance generally was adequate.
  • Most companies indicated that they did undertake formal assessments (69%) of their first aid requirements and that these assessments were done in conjunction with those for other H&S Regulations (57%).
  • 67% said they did consider the public and non- employees when assessing first aid requirements. In this context it is most likely to be contractors being considered.
  • 45% of companies have records indicating that first aiders have administered first aid during the previous 12 months and 71% in the last 3 years. A significant number of companies had also recorded some cases of first aid treatment to non-employees.
  • 79% of companies considered that first aid provision in the workplace was very beneficial or beneficial. Only 12% thought it was of minor or no benefit.
  • In contrast to the notion of benefit only 48% of employers thought that first aid had had any noticeable impact on reducing the effects of injury & illness at work.
  • Cost of first aid provision in the workplace was not generally (70%) reported to be a concern, though ‘lost time\' was the cost issue most commonly indicated as a concern.
  • Most first aiders receive training at the recommended interval of every 3 years, some have more frequent training; 13% have it every 2 years and 18% have it annually.
  • Most companies (58%) rely entirely on the statutory first aid courses to train first aiders and 83% think that HSE approval of first aid training providers is important.

Interested Party Survey Results (i.e. training companies, providers etc.)

  • 67% of interested parties believe that current guidance is adequate or very clear.
  • 68% of respondents believed that employers awareness of FAW was minor or poor.
  • 77% believed that there was fair or significant confusion regarding the role and responsibilities of an appointed person, although 84% believed this was a valid role.
  • 58% (in contrast to the employers) believed that employers did not undertake formal assessments of their first aid needs.
  • 67% of interested parties believed that first aid did have a noticeable effect in reducing the effects of injury & illness suffered at work, though 29% indicated it did not.
  • 74% indicated that cost was likely to be a concern to employers of which ‘lost time' and training costs were of greatest concern.
  • 51% believed that the current first aid training regime did not satisfy the objectives of FAW in reducing the impact of injury & illness at work and 67% believed that an alternative training regime should be considered.
  • 96% of respondents indicated that appointed persons should receive some form of formal first aid training.

A summary of some of the most significant recommendations

  • In the ‘short term' the FAW regulations should not be integrated with other health & safety regulations, since this would risk reducing the visibility & focus of the current regulations, resulting in a potential decline in provision.
  • In the longer term integration of the first aid regulations with other regulations relating to health & safety management is a logical and appropriate goal, for which preparations should be made.
    Current guidance, specifically the ACoP, requires amendment and revision to facilitate greater understanding by potential users of the requirements of the regulations. This includes both the content and the language of the guidance.
  • With respect to content, the issues most urgently requiring revision are associated with the process of assessment and the subsequent identification of first aid resources that are appropriate to make, proportional to assessed risk.
  • To achieve greater proportionality to the risk status assessed, a new level or levels of first aider is required, trained to a more basic level than the current full first aider. This may be achieved through the introduction of a new intermediate category of first aider or the upgrading of the present ‘appointed person' to include first aid competencies.
  • Training for any new more basic first aid level or indeed for appointed persons should be provided by HSE approved trainers.
  • The issue of ‘skill fade' amongst first aiders should be tackled by increasing the number of days training that first aiders are required to attend. The frequency and duration of any such additional training should be the subject of review, although any increase should seek not to raise the cost burden on employers significantly. In this context it should be considered in parallel with the introduction of any new level of first aider.
  • The role and responsibilities of the ‘appointed person' requires review, since these are not currently very well understood by employers.
  • The contents of first aid kits should be reviewed and upgraded in the light of new products and priorities associated with effective first aid provision. Guidance should encourage employers to stock first aid kit contents appropriate for their needs, rather than just the minimum required.
  • Guidance should include an explicit statement regarding the application of the regulations to small companies including very small companies with less than 5 employees.
  • There is potential value in the high level of enquiries to HSE regarding first aid, since this reflects (at least in part) a concern amongst employers & employees to make efforts to comply with the regulations. It would be valuable therefore to review the reasons for the relatively poor level of enquiries regarding other (more complex) health & safety regulations.

Three most cited obstacles to assessing and implementing first aid requirements

  1. Providing first aid cover for shifts, long working hours, out of hours work or shift variations.
  2. Providing first aid cover across diverse workplaces, work services, working practices, work buildings and on sites with wide geographical areas.
  3. Obtaining enough volunteer employees to take up a first aid role and/or finding the right calibre of staff for the role.

Last time a first aider was called on to provide first aid

Percent called on to provide first aid.

Past duration.

  • 45% 12 Months
  • 26% 3 years
  • 16% 5 years
  • 13% Not known

Addition first aid training taken up by employers


  1. Internal or External Refresher Course
  2. Defibrillator training
  3. Oxygen Administration
  4. One Day Basic First Aid
  5. Emergency First Aid
  6. Chemical First Aid (Aids, Cyanide, Toxics)
  7. Appointed Person
  8. CPR / Child/Infant

Job titles of those responsible for determining first aid resources in organisations

  1. Health & Safety Director/Manager/Officer (including EHS and SHE Managers and Loss Control Managers) 36%
  2. Other Managers (Factory, General, Centre etc.) 17%
  3. Managing Director or Chief Executive 16%
  4. Human Resources/Personnel Director/Manager/Officer 10%
  5. Occupational Health Manager/Physician/Advisor/Practitioner 5%
  6. Owner/Proprietor/Partner 3%
  7. Health & Safety Advisor 3%
  8. Health & Safety Committee 2%
  9. Facilities/Property Manager 1%
  10. Technical/Operations Director 1%
  11. First Aiders <1%
  12. Quality Assurance Manager <1%
  13. Accounts/Finance Director/Manager <1%
  14. Curator/Warden/Matron <1%
  15. Fire Officer <1%
  16. Risk Manager <1%
  17. Training Manager <1%
  18. Medical Officer <1%
  19. Company Secretary <1%
  20. Other <1%

Designated first aiders ‘alternative' training courses

  1. Appointed Person 18%
  2. Nurses or Occupational health Nurses 11%
  3. Emergency First Aid 9%
  4. Basic First Aid 9%
  5. St John's Ambulance 4.5%
  6. Territorial Army or Other Forces Related 4.5%
  7. In-house or Other Refresher Training 3%
  8. Life Guard 3%
  9. Diving First Aid 3%
  10. Medical Gases/Oxygen 3%
  11. SVQ 1.5%
  12. Teachers 1.5%
  13. Chiropractic Training 1%
  14. Paediatrics FIA 1%
  15. Heart Start 1%
  16. Red Cross Standard 1%
  17. First Aid at Sea 1%
  18. Offshore Medics 1%
  19. Aircrew 1%
  20. Royal Yachting 1%
  21. Fireman 1%
  22. Shipmaster 1%
  23. Healthcare Staff 1%

Cost of a FAW first aider

Annual First aider costs based on the above table:

a) Over a 3 year cycle - £561.00 per annum per first aider

b) Over a 6 year cycle - £450.00 per annum per first aider

The costs are calculated over 3 and 6 year cycles in parallel with the current first aid training cycles. It assumes payment of an honorarium (£100/annum) and takes an average employee cost per hour of £37.75 and an average working day of 7.5 hours per day. The costs do not include for first aid equipment or for additional work time involved in training or indeed the administration of first aid. Costs employed are present costs with no allowance for inflation. There is in addition no allowance of cost for lost revenue or production during training absence.
Cost of an Appointed Person

a) Over a 3 year cycle - £0 up to £128 per annum per appointed person

b) Over a 6 year cycle - £0 up to £128 per annum per appointed person

Currently there is no statutory requirement for the training of an appointed person although for cost purposes the allowance is made in the table below, with the assumption that this is renewed on a 3 year cycle. The same cost assumptions are made in relation to lost time as for first aiders above. It is also assumed that the role is not sufficiently responsible to warrant an honorarium.

Number of First Aid people

The approximate total number of people in employment (based on July 2001 figures) is 25,500,000. If we assume that 1 in 50 people have some sort of first aid cover, this might reasonably be made up from 1 in 500 being full first aiders and 1 in 55 being an appointed person. On the basis of these figures the following costs are derived.

No of First Aid Responsible People
3 Year Cycle Cost 6 Year Cycle Cost
1 in 500 First Aiders = 51,000 x £561 = 28,611,000 x £450 = 22,950,000
1 in 55 Appointed persons = 463,636 x £128 = 59,345,408 x £128 = 59,345,408
  Total = £87,956,408 Total = £87,956,408

Total industry cost range for establishing and maintaining first aiders therefore is £82.3 M up to £88 M per annum plus equipment. Making an assumption that one basic first aid kit is required for every 50 people in employment plus refills, based on current costs, this kit may reasonably be expected to be a total of £100 over 6 years. This provides an additional annual cost of £8.5m. In round figures this adds up to a total industry cost of approximately £100m.


The Effectiveness of FAW

  • The potential effectiveness of FAW is not challenged by a wide spectrum of employers because there is a wide perception within society generally, which is focussed in the workplace, that accidents can and do happen in spite of the best safety management. In which case first aid is a wise precaution to adopt.
  • Within industry sectors where there are manifest risks in the workplace generally associated with manual work activities, accidents and injury are more common and this results in more frequent use of first aid services. These organisations therefore derive most benefit from first aid in the workplace through minimising lost time resulting from injury or illness at work. Hence the organisations who utilise first aiders most tend to appreciate the benefits most. As the rate of first aid application declines in organisations with a lower rate of injury & illness however, the practical benefits of maintaining first aid resources also decline.
  • Low risk companies and organisations have less direct incentive to establish and maintain first aid resources since the practical benefits are less tangible. There remains however a considerable benefit to employees who derive significant "comfort" from the provision of appropriate first aid cover.
  • The objective economic measure of FAW would be the establishment of the quantity of ‘lost time\' that has been saved as a result of first aid intervention, for all severity categories of injury or illness at work. This however has not been effectively established during this study; although by the evaluation of a wide range of views and experiences through the survey process, first aid has proved to be a resource which has achieved significant penetration into UK employer organisations. The degree of compliance of organisations to the specific requirements of FAW however presents significant room for improvement.

Could FAW be Better Integrated with Other Health & Safety Management Arrangements?

  • Logically there is some benefit to be gained from closer integration of first aid at work with other existing safety management arrangements, accruing from the integration of the wide review/assessment process that the first aid and other regulations require. Indeed the requirements of the Management of Health & Safety at Work Regulations, in principle, should provide the ideal mechanism for implementation of first aid along with other safety considerations and precautions that these regulations advise.
  • In practice the effect of any such integration would be very likely to reduce the effectiveness of the current first aid regulations, through a reduction in their visibility and focus and resulting in a potential decline in provision. The FAW regulations are distinguishable by their separate status, which gives them greater visibility and accessibility.
  • Integration of the requirements of the FAW regulations with other general regulations may result in a decline in the level of enquiries regarding first aid because of a perceived linkage with safety regulations which require greater effort to achieve compliance with and hence risks lower levels of compliance.
  • The process of risk assessment in the workplace is not a well understood procedure, particularly with non health & safety trained individuals, hence raising the significance of the process of risk assessment in the workplace may deter many employers who would otherwise have been prepared to make reasonable first aid provisions following a basic consideration of their circumstances (whether or not this constituted a formal assessment).

First Aiders and Employees Attitudes to the Requirements of the FAW Regulations

  • First aiders and employees attitudes to first aid is a positive one throughout the spectrum of industry and commerce, and from this perspective the general objectives of the current FAW regulations are well appreciated and understood.
  • With respect to the detail of the regulations in terms of what level of provision could and should be made in the workplace, the regulations are generally very poorly understood apart from those with a professional interest in the subject. Apart from the "need for employers to make an appropriate first aid provision in the workplace, including trained personnel" most people have a very limited awareness of the requirements.
  • The training received by first aiders concentrates on the practical issue of delivering first aid to a casualty, it does not focus on the requirements of the regulations, hence even first aiders as a group have a relatively poor awareness of the level of first aid resource their employers are obliged to make. They do however generate a much keener appreciation of the potential benefits that their role can have to colleagues (and others) who sustain injuries or fall ill.
  • A significant proportion of first aiders and employers consulted each acknowledged that the current 3 year period between training courses is ‘too long' resulting in noticeable ‘skill fade' and consequent reduction in the potential effectiveness (and confidence) of first aiders. The advantage of more frequent training is therefore accepted and most employers would sanction a modest cost of extra training.

Requirements for Further Advice & Guidance

  • Current HSE guidance and information was regarded as being "adequate" by a majority of employers and interested parties. Despite this however there is clear evidence that guidance and information could be clearer; this includes the high level of enquiries on first aid made to the HSE and the fact that there is evident lack of awareness and/or confusion with regard to the precise requirements on behalf of employers to achieve compliance.
  • The single most criticised element of guidance and information on first aid is in relation to the assessment process. The view most widely expressed was that guidance did not adequately articulate the assessment process and furthermore did not present a clear route to specific outcomes (first aid provisions in terms of equipment & trained personnel).
  • Table 1 in the ACoP provides the most widely adopted options for provision of first aid trained personnel in the workplace based on employee numbers and a notion of the ‘risk status' of the company. Employers would most often by pass the assessment process in favour of the options highlighted by table 1 and may as a result make an ill informed choice of resource.
  • The format and language of the ACoP is not seen as being accessible to the majority of its potential audience. The document is best appreciated by health & safety professionals who are familiar with the purpose and language of ACoP's. Many non health & safety trained employers however suggested they had difficulty in determining clear requirements from the document.
  • The three most popular topics of enquiry to HSE Infoline by far are associated with training requirements, the number of first aiders and the contents of first aid boxes. These are all fundamental issues which should be easily determined by employers from guidance, but it is not in practice and this at least in part relates to the effectiveness of the guidance in communicating this information. Currently it is not effective. However, it is also the case that most people ringing Infoline to enquire on these first aid topics have not referred to guidance before they call.
  • The contents of first aid kits were considered by ‘interested parties' to require review and updating. Valuable additional first aid kit items were identified for inclusion including, sterile fluid in pods or bottles, foil blankets and resuscitation aids for assisting mouth to mouth resuscitation. The contents too might usefully be expressed in terms of a minimum number of items, emphasising the fact that restocking will be required as items get used.
  • The role of appointed persons was poorly understood amongst a large section of employers particularly those with no health & safety training who would be less likely to have detailed knowledge of the regulations in common with most ordinary employees. With such evident confusion regarding the term, it is apparent that some employers regard "appointed persons" as "first aiders".
  • The role of an appointed person was considered to be a valid one by most employers and interested parties which would benefit from greater visibility and an enhanced status if it were to require structured training.
  • Small companies with less than 5 employees have a clear perception that the FAW regulations along with other health & safety regulations do not apply to them by virtue of an exemption due to their small size. This is not a direct problem associated with guidance & information regarding the FAW regulations, but guidance and information would clearly benefit from making an explicit statement regarding the application of the regulations to all employers. This coupled with better guidance regarding assessment and subsequent ‘appropriate' provisions for small and low risk companies would perhaps encourage such companies to take on appropriate first aid resources, including first aid training (to an appropriate level).