National Back Exchange: Back to the future

Musculoskeletal disorders (MSDs) remain a hot topic for occupational health (OH) practitioners representing (alongside stress) one of the two biggest causes of sickness absence from work.

The Labour Force Survey for the year 2007-08 (Health and Safety Executive (HSE) 2009) found a return to the long-term slightly downward trend in estimated incidence rates of self-reported work-related MSDs since 2001-02 (following a slight blip in the year 2006-07).

National Back Exchange (NBE), the association for people interested in back care and the prevention of work-related musculoskeletal problems, has been tackling this problem for 21 years and has its annual conference next month. Most members are qualified healthcare professionals who have gone on to become manual handl­ing specialists.

Impact of MSDs

OH practitioners are all too familiar with the cost to individuals experiencing MSDs – such as pain and suffering, impact on daily life and potential loss of income. There is also the great cost to society, and MSDs are a priority area for the HSE. It states that ‘back disorders are the most common form of ill health disorders at work – prevention and management are key’1, and ‘11.6 million working days a year being lost to work-related MSDs’.2

Raistrick (2008) advises: “It would be prudent to actively manage existing cases of work-related musculoskeletal disorders while concurrently using ergonomics to redesign work situations to reduce the extent of work-related musculoskeletal disorders in the future”. Some of the costs of MSDs to employers listed by Raistrick include sickness absence payments, management of sickness absence and return to work, cover for absent workers, reduced business capacity, and legal costs associated with personal injury claims or prosecution.

OH practitioners strive to improve the situation, helping employers and staff implement safer manual handling policies using an ergonomic, risk assessment approach in line with the Manual Handling Operations Regulations. Some organisations also employ manual handling specialists, usually NBE members, with such job titles as back care adviser, manual handling adviser/trainer, and moving and handling adviser/trainer.

The Manual Handling Operations Regulations came into effect on 1 January 1993 (under the terms of the Health and Safety at Work Act 1974), thereby implementing the European Directive (90/269/EEC). NBE founding member and qualified OH nurse Maggie Williams, then working at the Royal Free Hospital, remembers: “We were really excited as these regulations added power to our elbow by putting a clear duty onto employers. Our members could now get top-level management to support the introduction of comprehensive manual handling policies involving risk assessment.”

The regulations are based on the ergonomic approach of adapting the workplace to suit the needs of people working there (rather than the other way around). The approach involves risk assessment by competent people, and this is where the manual handling specialist – working in-house or on a consultancy basis – can help. As well as running training sessions, performing assessments and problem-solving, they can advise on such matters as policy, the latest equipment, workplace adaptations and improvements and audit.

Back Exchange background

In the 1970s increasing numbers of nurses were hurting their backs at work. Dealing with such cases was a major part of the work of the legal department at the Royal College of Nursing (RCN). The RCN’s OH adviser, Paul Lloyd, set up and chaired a multidisciplinary panel – the Advisory Panel on Back Pain in Nurses – with representatives from various healthcare professions. The Department of Health and Social Security funded the Ergonomics Research Institute at the Robens Institute, University of Surrey, to carry out a five-year study (1979-1984). A summary report, Back Pain in Nurses (1986), proposed ergonomic solutions.

Some hospitals created manual handling specialist posts to address the difficulties of moving and positioning patients more safely and comfortably while reducing the risk to nurses. Post-holders were qualified healthcare professionals, usually physiotherapists or nurses, and some of them began to meet regularly, identifying problems and sharing ideas and solutions. They formed ‘Back Exchange’ in London, and this group was the beginning of the National Back Exchange, which now has 21 affiliated local groups, as well as international links.

Changing behaviour

During the 1990s, hundreds of manual handling specialist posts were created in the health services, often within OH departments. There were funding difficulties and also resistance to changing behaviour – for example, by using manual handling equipment such as hoists. Maggie Williams explains how NBE members helped to change working practices.

“It was changing behaviour. Nurses would say: ‘It’s quicker to lift the patient’. And employers would say: ‘We can’t afford new equipment. We’ve managed without it up to now’. So that involved making a business case and several members of Back Exchange did just that – demonstrating cost savings following the introduction of equipment and appropriate staff education and training.

“Bed management schemes were introduced following the outstanding example of Clive Tracy at Kings College Hospital. He conducted a study looking at all the different aspects like mattress condition, how many old beds were left in corridors awaiting repair, how the nurse might have hurt herself because the brakes didn’t work,” she continues. “He demonstrated cost savings to the trust – that was the crunch point. Kings took up the total bed management scheme and it was a great success.

“Now almost everywhere in hospitals there are not only hoists but electronic beds and a host of other manual handling aids. Patients can be moved more safely and comfortably and healthcare workers’ backs safeguarded.”

The Royal College of Nursing Legal Department now rarely deals with back injury claims from nurses. NBE claims to have played a part in this occupational health and safety success story. Nevertheless, expert witness Jacqui Smith (MSc, MCSP, CertOH), consultant occupational physiotherapist and editor of NBE’s The Column, stresses that there is no room for complacency. Smith says that much of the risk has now shifted from health services to social services where some dependent, chronically ill people are receiving suboptimal care in their own homes from care workers and carers trying to do their best in cramped environments – often with little training, equipment, supervision or support.

Juliet Fox Linton (RGN, OHN) moving and handling trainer for Surrey Social Services, agrees: “OH practitioners and NBE members have vastly improved awareness and practice in moving and handling both for the health service and in-house social services staff. However, the area now most in need of scrutiny, review and improved practice is the use of agency care workers or those employed by the service-users themselves [under the direct payments scheme], as this is increasingly the way that social care is being delivered.

“There are wide inconsistencies in the quality and content of moving and handling training available to these workers, as well as supervision at work and monitoring of work practices. This increases the risk of poor practice and possible injury to both service users and care workers which undermines the achievements attained elsewhere.”

NBE is 21 this year, and it is clear that the association continues to provide a valuable networking forum. As members celebrate the anniversary at their conference next month, they will also, as they do every year, be trying out the latest equipment, sharing problems, finding solutions, and generally striving to improve occupational health and safety in the manual handling arena.

Katie Oakley is a freelance writer, researcher and editor of Occupational Health Nursing (3rd ed), published in 2008 by Wiley-Blackwell.

National Back Exchange

National Back Exchange (NBE) is a multidisciplinary association which was founded in 1988, for those with an interest in back care and the prevention of work-related musculoskeletal problems. As well as publishing best practice guidance and a journal (The Column), NBE provides a UK-wide forum with local branch meetings, where members tackle the latest manual handling problems and agree potential solutions.

Membership: about 1,200

Local groups: 21

NBE aims to:

  • Promote the exchange of information and ideas about back care

  • Develop and promote common standards of training in safer handling

  • Promote initiatives and act as a forum for the evaluation and audit of current practice in all matters associated with back care

  • Lobby employers to provide back care advisory services to reduce work-related back problems

  • Provide support and advice for members.




3 Health and Safety Executive website:

4 Health and Safety Executive (March 2009) Self-reported work-related illness and workplace injuries in 2007-08: Results from the Labour Force survey

5 Health and Safety Executive (1992) Manual Handling Operations Regulations

6 National Back Exchange website:

7 Raistrick, Claire (2008) Musculoskeletal disorders and ergonomics in Oakley (ed) Occupational Health Nursing. Wiley-Blackwell

8 The Robens Institute University of Surrey (1986) Ergonomics Research Unit Back Pain in Nurses Summary and Recommendations

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