Essential guide to legionnaires disease prevention in UK GP Practices

Managing a busy GP practice involves juggling countless priorities, from patient care to regulatory compliance. One crucial aspect of ensuring a safe environment for both patients and staff is managing the risk of Legionnaires' disease. While outbreaks linked directly to well-managed GP practices are uncommon, the potential risk exists in any man-made water system, making proactive prevention essential.

This guide provides UK GP Practice Managers with essential information on understanding and controlling Legionella risks, aligning with legal requirements and best practices. We'll cover what Legionnaires' disease is, why risk assessment is critical, and the practical steps you need to take to keep your practice water systems safe.

Understanding the risk: What is legionnaires' disease and why does it matter for GP practices?

Legionnaires' disease is a severe form of pneumonia caused by inhaling small droplets of water (aerosols) contaminated with Legionella bacteria.Importantly, it's not spread from person to person; the source is environmental.

Legionella bacteria are common and found naturally in low numbers in sources like rivers and lakes.They become a potential health risk when they enter man-made water systems – like the hot and cold water systems in your practice – and find the right conditions to multiply.These conditions include:

Water temperature: The bacteria thrive between 20C and 45C.
Stagnation: Areas where water doesn't flow regularly allow bacteria to grow.
Nutrients: Biofilms (slimy layers inside pipes), scale, rust, and sludge provide food for the bacteria.

While anyone can potentially get Legionnaires' disease, certain groups are at much higher risk, including individuals over 45, smokers (current or former), and those with chronic respiratory, heart, kidney, or liver disease, diabetes, or weakened immune systems. As GP practices routinely care for many patients within these vulnerable groups, maintaining safe water systems is a direct patient safety imperative.

The cornerstone of compliance: Your legionella risk assessment

The foundation of effective Legionella control – and a legal requirement under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health (COSHH) Regulations – is a Legionella Risk Assessment (LRA). The Care Quality Commission (CQC) also explicitly expects practices to have a current LRA in place.

This assessment must be carried out by a competent person – someone with the necessary skills, knowledge, and experience to identify risks accurately. This doesn't necessarily mean you must hire an external contractor; a suitably trained member of your practice team could potentially fulfil this role, provided they meet the competency requirements.

The LRA involves systematically examining your practice's water systems to:

Identify potential sources of risk (e.g., water storage tanks, infrequently used taps/showers, pipework configuration).
Assess the risk of harm, considering the susceptibility of your patients and staff.
Determine the necessary control measures to prevent or minimise risk.

Crucially, the LRA is not a one-off task. It must be regularly reviewed – typically at least every two years, or sooner if there are significant changes to the system or its use, if monitoring shows controls aren't working, or if new guidance emerges.

Practical prevention strategies: Keeping your water system safe

Your LRA will determine the specific actions needed for your practice. However, core prevention strategies recommended by the Health and Safety Executive (HSE) in their Approved Code of Practice L8 (ACoP L8) and technical guidance HSG274 Part 2, along with healthcare-specific guidance like HTM 04-01, include:

Temperature control: The first line of defence

This is the most effective way to control Legionella growth:

Hot water: Store it at 60C or higher in the cylinder (calorifier). Ensure it reaches outlets at 50C or higher (55C or higher is recommended in healthcare settings per HTM 04-01) within one minute of running the tap.

Note: Thermostatic Mixing Valves (TMVs) are often needed at outlets like hand wash basins to prevent scalding at these temperatures and require regular maintenance.
Cold water: Keep it stored and distributed below 20C. Check the temperature at outlets after running the water for up to two minutes.

Regular temperature checks (e.g., monthly for key sentinel outlets, six-monthly for cold storage tanks) are vital to ensure these targets are consistently met.

Flushing routines: Simple, effective, essential

Water stagnation is a major risk factor.Any outlet not used regularly (at least weekly) can allow Legionella to grow. This includes taps and showers in consulting rooms, treatment areas, staff kitchens, or accessible toilets that might see infrequent use.

Implement a routine of weekly flushing for these outlets until the water runs at a consistent temperature (reflecting the incoming supply or circulating temperature).
Keep records of when flushing is done.
Practical Tip: Rather than trying to meticulously track which specific taps haven't been used, many practices find it simpler and safer to implement a routine where all designated low-use taps are flushed weekly as a standard procedure. This reduces the chance of missing an outlet and simplifies the task for staff.

Cleaning and maintenance: Beyond flushing

Keep the system clean to remove nutrients for bacteria:

Shower-heads and hoses: Dismantle, clean, and descale them regularly (e.g., at least quarterly).
Cold water storage tanks: Inspect annually for cleanliness, ensure they are properly lidded, and clean/disinfect if needed.
Thermostatic Mixing Valves (TMVs): Ensure they are part of your planned maintenance schedule as per manufacturer and guidance recommendations.

System design considerations

While often part of initial setup or refurbishment, be aware of:

Dead legs: Sections of pipework where water cannot flow (e.g., capped-off pipes from removed sinks).
These should be removed wherever possible. If not, they need careful management, potentially including regular flushing if feasible or specific disinfection protocols outlined in your LRA.
Materials: Use appropriate pipework and fitting materials that discourage biofilm growth.

Responsibilities, records, and training: Embedding safety

Effective management requires clear accountability and ongoing diligence:

Responsible person: Appoint a competent individual (or individuals) with the authority and knowledge to manage Legionella controls.
Record keeping: This is a legal requirement and crucial for demonstrating compliance. Keep detailed records of your LRA, the appointed responsible person(s), your control scheme, all monitoring results (temperatures, flushing logs), cleaning/maintenance activities, and staff training.
Staff training: Ensure anyone involved in Legionella control – from the responsible person to staff performing weekly flushes – is properly trained and understands their role and the importance of the procedures.

Key takeaways for busy practice managers

Risk is real but manageable: Legionella is present in water systems, but established control measures, properly implemented, are highly effective.
LRA is fundamental: Ensure you have a suitable, sufficient, and up-to-date Legionella Risk Assessment conducted by a competent person.
Focus on practical controls: Prioritise consistent temperature management and regular flushing of infrequently used outlets. Simple, routine actions make a big difference.
Keep good records: They are essential for compliance and demonstrating due diligence.
Review regularly: Both your LRA and your control measures need periodic review to ensure they remain effective.

Managing Legionella doesn't need to be overly complex, especially in smaller practices with simple systems. By understanding the risks and implementing proportionate, practical controls based on your risk assessment, you can effectively protect your patients and staff and meet your regulatory obligations.

Further Information:

HSE - Legionella and Legionnaires' disease: https://www.hse.gov.uk/legionnaires/
HSE - ACoP L8: https://www.hse.gov.uk/pubns/books/l8.htm
CQC - GP Mythbuster 27: Legionella: https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-27-legionella

Disclaimer: This article is for informational purposes. It does not constitute legal or specific technical advice. Practices should consult with competent advisors for specific circumstances and always refer to the latest official guidance from the HSE, NHS England, CQC, and other relevant bodies.