Trust worthy

You are more likely to be killed by an infection caught in hospital than by a car accident, and one in ten people who stays as an in-patient will acquire an infection. These infections kill around 5,000 people every year. Such headline-grabbing statistics, which were compiled by Watchdog Healthcheck, are among the figures that have put hospital cleanliness in the firing line – and cleaning contractors have made convenient scapegoats.

Recent media interest in the issue comes primarily as a result of a government initiative to clean up NHS hospitals. But the initiative has also given contractors the chance to clean up their image, too.

Last July, Lord Hunt, then health minister, announced measures aimed at improving cleanliness and patients' experiences of their local hospital. At its launch, Lord Hunt said the initiative, part of the NHS Plan, 'puts patients at the heart of the health service'.

'We are determined to improve patients' experiences of the NHS,' he said, 'and a key element in achieving this is to ensure we improve hospital cleanliness.' To kick-start the project, Lord Hunt made available an extra £31 million that hospitals could spend immediately.

Generally, the initiative has been welcomed by the contract cleaning industry. For Chris Gray, managing director of Medirest, which has a turnover of £160 million and employs 12,000 staff, the NHS Plan is crucial. 'There has been a watershed in the change of attitude towards the provision of services,' he says. 'The patient is now an individual – not just on a production line.'

On a holistic level, Gray believes that good support services are vital to overall patient care. 'There is now recognition of the importance of food and cleaning,' he says. 'Hospital stays are a stressful time for patients and their visitors. For these people, cleanliness and good food are visible and easily understandable, whereas the clinical aspect is all a bit of a mystery. It is important to address the things that patients can actually see to make their stay in hospital less stressful.'

Patrick Boyle, a contract manager at Initial Hospital Services, also welcomes the new approach. 'For the first time, support services are not regarded as somewhere from which to extract money,' he says. 'They are considered central to good patient care. Money has been withdrawn from these services for years, but now the emphasis is on quality rather than cost-cutting.'

In addition to the extra funds, at the NHS Plan's launch Lord Hunt also announced that NHS trusts would be inspected by Patient Environment Action Teams (PEATs). The teams would include representatives of the Patients' Association, and NHS bodies such as Infection Control Nurses. Lord Hunt advised all trusts to draw up action plans for these inspections.

For Boyle, the government initiative was a welcome change. 'From the outset, PEAT brought a different approach,' he says. 'The government has recognised that it can't look at cleanliness in isolation. For the first time, this has brought together private contractors with the in-house staff. The contractor used to work in isolation but now there is a team environment.'

My reservation is that because there is a one-off cash injection, the continuation or development of this system has been restricted

Geoff Callan

Boyle believes that PEAT has raised the profile of hospital cleanliness, and staff are reacting to this positively. In one London trust, he says contractor staff have risen to the challenge.

'We had to do a lot of work with ward managers to take responsibility, as there was a real need for all parts to work together,' says Boyle. 'We did not meet with much hostility as the government project has highlighted the problems and it has become a great motivator to improve things.'

The trusts are inspected on about 19 standards and given marks between one and four, one being the highest. The trusts are then given a rating according to a traffic light code – green for an exemplar hospital, amber for an average trust, red to a trust that must make many improvements. The initial inspections are followed up later, to check that action has been taken, and the results released to the local media.

The government initiative was greeted with a wave of publicity, yet some questions still remain unanswered. For example, as Mike Jepson, managing director of Initial Hospital Services, says: 'This is a good exercise as it raises this issue's profile, but it is not a precise science.'

Gray of Medirest believes there is a fundamental flaw. 'The inspections are not set on a level playing field,' he says. 'For example, if there is a hospital that opened last year compared with a huge Victorian hospital, it is easy to see which one will be easier to upkeep – this represents two extremes.'

Geoff Callan, adviser to NHS Estates and chairman of the Health Facilities Management Association, also expresses concern. 'PEATs have been welcomed, but their remit was a lot more than we initially thought it would be,' he says.

Jepson agrees that PEATs have had more to deal with than just cleaning . 'The NHS Plan in the summer gave £30 million to clean up – most of this money has not gone into cleaning, but into maintaining the fabric of the hospital, for example repainting signage,' he says. 'The trusts had to put their cases forward for where they wanted the money to go. Some went into one-off cleans, but so far there has been little permanent funding.'

Callan is also concerned about funding. 'My reservation is that because there is a one-off cash injection, the continuation or development of this system has been restricted. Whether support services are carried out in-house or by a contractor, they can only do what they can with the funds they have. We all want to improve quality but funding is crucial.'

Boyle believes the responsibility ultimately lies with contract managers. 'The emphasis now is on quality rather than cutting costs,' he says. 'Money has been withdrawn from the support services for years. Having said that, if an operation is managed properly it can work.'

Bizley is vocal in his criticism of Alan Milburn. He says the government is wrong to condemn contract cleaners for the state of some hospitals

For example, at a hospital in west London, Boyle helped set up a central administration area, so that managers' time was freed up for them to walk around the hospital monitoring and assessing the trust.

But until there is a set of national cleaning guidelines, critics will always argue that the inspections are arbitrary. The Cleaning and Support Services Association (CSSA), together with the British Institute of Cleaning Science (BICSc) and three contractors – ISS Mediclean, Initial Healthcare and Granada – have been taking part in the NHS Estates Clean Hospitals Best Practice Group. This also involves eight exemplar NHS Trust hospitals, and representatives from the Association of Domestic Managers (ADM) and the Infection Control Nurses.

The group has recommended that all cleaning operatives should be trained and certified as competent in the BICSc's new foundation programme. It also recommends that to qualify for 'best practice', all cleaning operatives should be trained to meet the relevant National Occupational Standards for cleaning and support services. They should also be certificated as competent by gaining the relevant Level 2 NVQ/SVQ.

The group is also suggesting that there should only be one 'best practice', and that the standards should be based on statements in the National Occupational Standards for the cleaning and support services industry. In other words, service delivery can be demonstrated and assessed by referring to an outcome statement.

Michael Bizley, director general of the CSSA, believes this will ease performance assessment. 'The benefits of using this system,' he says, 'are that service providers and hospital management will be using a common language for the essential purposes of measuring the competence of individual members of staff, and the overall performance of the provider.'

Final guidelines were due at the end of March, as TheFB went to press. But, while contractors have remained in the firing line, Bizley has been quick to defend them. He is vocal in his criticism of current health minister Alan Milburn's attitudes to contract cleaners. In a letter to the minister, Bizley says the government is wrong to condemn contract cleaners for the state of some hospitals.

'Only about 35 per cent of the market for cleaning hospitals is outsourced to cleaning support service contractors,' he says. 'The other 65 per cent is provided by in-house operations.'