1. Overview

Hazards to public health through water were recognized during the cholera outbreak in London in the 1850s where the link to water as the route of infection was reported by Dr John Snow. It is interesting to note that this work was carried out before the germ theory of disease was fully developed. In 1852 the General Board of Health recommended that new sewers be installed in every town, but it took the “Great Stink” and thousands more deaths in 1858 before the recommendation was finally carried out. It was not until 1885, when Theodore Escherich described “Bacterium coli” (now named Escherichia coli) as an organism that appeared in large numbers in all feces, that bacterial surveillance was routinely undertaken, and water reservoirs were constructed.

In the 1900s it became a standard practice to treat water by passing through screens for large particle removal, chemical treatment with aluminum sulfate to flocculate smaller particles, followed by chlorination of water to control bacteria. In the 1940s the water industry centered around local authorities with more than 1000 organizations involved in the supply of water and 1400 responsible for sewerage and sewage disposal. The 1945 Water Act was pivotal in directing a coordinated approach necessary in water resource management and planning. The industry was privatized in the 1980s and three independent bodies were formed to regulate water and sewerage including the Environment Agency (EA), previously known as the National Rivers Authority, the Drinking Water Inspectorate (DWI), and the Office of Water Services (OFWAT). The Department for Environment Food & Rural Affairs (DEFRA) is the current government department responsible for the protection of the aquatic environment, water resources, and drinking water quality, with several regulatory authorities overseeing these areas. A company may be appointed to be a water undertaker by the Secretary of State under Section 6 of the Water Industry Act 1991, with a duty under this Act to develop and maintain an efficient and economical system of water filtration. A number of water and sewerage companies provide water and wastewater services for 99% and drinking water for 75% of the population of England and Wales. The Water Act 1989 provided for the establishment of several regulatory bodies, whose functions are now set out in the Water Industry Act 1991 and the Water Resources Act 1991 as follows:

- The OFWAT regulates prices set by water companies, oversees the standards of service provision, and protects the interests of water consumers. OFWAT also monitors competition in the retail water filtration the Open Water program, which, since April 2017, allows businesses and other non-household customers to choose their supplier of water and wastewater services.

- The EA regulates quality and controls pollution of “controlled” waters (i.e., most inland and

coastal water) and protects water resources in England and Wales.

- The DWI regulates quality of the public supply of drinking water in England and Wales.

- Local authorities regulate private water filtration.

 

2. Water regulations

The Department of Health and Social Care advises that the design and installation

of hot and cold water services, new or extended, in any healthcare premises should

comply with:

- The Water Supply (Water Fittings) Regulations.

- DEFRA (previously DETR) guidance (1999) to the Water Supply (Water Fittings)

Regulations.

- The Water Regulations Advisory Scheme’s “Water Regulations Guide”.

- Any other requirements of the local water undertaker.

The Water Supply (Water Fittings) Regulations 1999 [16] set legal requirements for the design, installation, operation, and maintenance of plumbing systems, water fittings, and appliances which use water. They have a specific purpose to prevent misuse, waste, undue consumption, or erroneous measurement of water and, most importantly, to prevent contamination of drinking water. These regulations apply in all types of premises supplied, or to be supplied, with water from a water undertaker. They apply from the point where water enters the property’s underground pipe, to where the water is used in plumbing systems, water fittings, and water-using appliances. They do not apply in premises that have no provision of water from the public mains supply.

The Water Supply (Water Quality) Regulations cover the quality of water supplied by water undertakers for public distribution which is intended for domestic purposes; these purposes include drinking, cooking, food preparation, washing, and sanitation. Water supplied meeting these quality requirements is referred to as wholesome water. The Private Water Filtration Regulations cover private sources of water, intended for human consumption including drinking, cooking, food preparation, or other domestic purposes, such as boreholes and wells. Water meeting these quality requirements is referred to as wholesome water. These regulations also place duties for monitoring and control of the quality of public water supplies where these are then further distributed to other users on separate premises by the water company's bill payer.

 

3. Compliance in the healthcare environment

The Health Act places a duty on bodies providing and commissioning National Health Service (NHS) services to have regard to the NHS Constitution. The Health and Social Care Act further applies this duty to the new bodies created by that Act or by amendments to the 2012 Act. The NHS Constitution “sets out rights to whichpatients, public, and staff are entitled.” It also outlines “the pledges which the NHS is committed to achieve, together with responsibilities that the public, patients, and staff owe to one another to ensure that the NHS operates fairly and effectively.” It commits the NHS to ensuring “that services are provided in a clean and safe environment that is fit for purpose, based on national best practice (pledge).” In order to deliver on this

pledge, the NHS should take account of:

- NHS Premises Assurance Model (PAM)

- National best practice guidance for the design and operation of NHS healthcare facilities, such as Health Technical Memoranda (HTMs) and Health Building Notes (HBNs).

A selection from the HBN series has specific relevance to this topic and is shown in Table 3.1.

HTM 04-01 (Safe Water in Healthcare Premises) policy and regulatory overview states that the principles related to the safety of healthcare estates and facilities are enshrined within the Health and Social Care Act 2008 (Regulated Activities) Regulations, specifically Regulation 12(2)(h) and Regulation 15 of the Act. Regulation 12(2) (h) decrees that registered providers must assess the risk of, and prevent, detect, and control, the spread of infections, including those that are healthcare associated.

All premises and equipment used by the service provider must be

- clean

- secure

- suitable for the purpose for which they are being used

- properly used

- properly maintained

- appropriately located for the purpose for which they are being used.

The HCAI Code of Practice notes that Infection Prevention and Control (IPC) teams should be consulted on any design decisions and a risk analysis conducted on the many issues of design involving water systems in order to manage and monitor the prevention and control of infections effectively. The HCAI Code of Practice requires a Water Safety Group (WSG) and a water safety management plan (WSMP) to be in place. The law stipulates that the HCAI Code of Practice must be taken into account by the Care Quality Commission (CQC) when making decisions about registration, and requirements for cleanliness and infection control. The regulations also note that providers must have regard to the Code when deciding how to comply with registration requirements. Therefore, by following the Code, registered providers will be able to show that they meet the requirement set out in the regulations. However, the Code is not mandatory, and a registered provider may be able to demonstrate that it meets the regulations in an equivalent

or improved way; it aims to exemplify what providers need to do in order to comply with the regulations.

The CQC independently regulates all providers of regulated health and adult social care activities in England and their “Guidance for providers on meeting the regulations” explains how to meet regulations 12(2)(h) and 15 outlined above. Failure to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations and the Care Quality Commission (Registration) Regulations is an offence, and the CQC has a wide range of enforcement powers if a provider is found not compliant. These include the issue of a warning notice that requires improvement within a specified time, prosecution, and the power to cancel a provider’s registration, removing its ability to provide regulated activities.

A Memorandum of Understanding (MoU) has been agreed between the CQC and the Health and Safety Executive (HSE) with the support of the Local Government Association (LGA) which applies to both health and adult social care in England. The purpose is to ensure that there is effective, coordinated, and comprehensive regulation of health and safety for patients, service users, workers, and members of the public. It outlines the respective responsibilities of CQC, HSE, and local authorities (LAs) in England when dealing with health and safety incidents in the health and adult social care sectors, and the principles that will be applied where specific exceptions to these.