Keeping a hospital clean does not require a lot of money or complicated equipment. It does require will. It requires someone to exercise authority and take responsibility
Published: 24 June 2007
In the same week that saw the Conservative party announce its plans for the National Health Service came news that one in four NHS organisations in England is failing to comply with basic hygiene standards. Survey after survey reveals that patients are more concerned about catching an infection in hospital than any other issue.
The rise of the hospital superbug is the visible sign of a bureaucracy in crisis. Cases of MRSA in England and Wales have increased by 600% in the past decade alone, according to government figures. Britain has one of the worst records in Europe. The danger of contracting a bug here is more than 15 times higher than the next safest countries. Hospital-acquired infection (HAI) affects 300,000 people a year, claiming as many as 20,000 lives, with more than 5,000 a year dying of hospital superbugs such as MRSA.
Keeping a hospital clean does not require money or complicated equipment. It does require will. It requires someone to exercise authority and take responsibility. Florence Nightingale understood this when she cut the fatality rate of wounded soldiers from 40% to just 5% by imposing basic standards of hygiene and sanitation. She organised her nurses on almost military lines and subjected them to military discipline.
What do we have instead? One former matron, now in audit work, pointed out the difficulty of disciplining a nurse for incompetence in the NHS today. Modern management is meant to “nurture” its employees. “You can’t bawl them out or they’ll sue you for harassment,” she explained. Instead, “in a nice, soft voice, you have to ask if that was the way she had been taught? Did she consider it appropriate?”
The hospitals I visited during a year’s research appeared helpless to do anything about their wards and staff. A sister in charge of a ward has little say in how her ward is cleaned, when it is done or by whom. Certainly she has no power to discipline cleaners. All she can do is complain to the cleaning manager who deals with the outside contract cleaners.
One Filipina nurse complained: “No one tells the cleaner to change their water when it gets dirty. If you don’t stipulate in the contract that the water should be changed four times when you wash a particular ward, they won’t do it.” She was shocked that her NHS hospital had no night cleaners as they do in the Philippines, she said.
NHS staff themselves often fail to take the risk of HAI seriously. At a hospital board meeting I attended, a consultant admitted: “I don’t get stroppy with staff if they do not wash their hands.”
“I do,” replied another doctor. “But you are a surgeon,” pointed out the first, “and I am just a gentle physician.” Stroppiness is not seen as a virtue in the NHS.
I was standing outside a side room, containing a patient with MRSA, talking to a matron and a nurse manager from infection control. Earlier I had been shown the apron and glove dispenser at the entrance of the room. Every nurse is supposed to put these on before touching the patient, then remove them before leaving the room. Suddenly I noticed a nurse walk in, see to the patient and then depart. She had not, despite the presence of her matron and infection control manager, touched the dispenser.
Neither woman appeared to notice. In my astonishment I interrupted them. Had I misunderstood? Was I being very stupid? It appeared not. The matron tut-tutted. “You’ve got to have eyes in the back of your head with these girls,” she said. The infection control manager nodded sympathetically. “Doctors are far worse,” she added. There was no question of a reprimand, let alone the sack.
Compare this with the enforcement of health and safety legislation elsewhere. One industrial chemist, who found himself a patient of the NHS, was horrified when he witnessed a similar scene. He would have been sacked on the spot for not wearing the protective clothing or equipment provided by his employers. NHS health and safety legislation, so powerful that it can close down a hospital, does not – as the chief executive of one hospital pointed out to me – even include infection control.
So will “autonomy and accountability”, the Conservative proposals for NHS reform, do anything about our dirty buckets? The main feature of the report is how little it differs from Labour’s own NHS reforms.
Patients, the Conservatives promise, can choose to be treated in the private or public sector as long as the cost is the same or below that of the NHS. If the cost is higher, patients cannot top up the NHS with their own money. This is exactly what many might wish to do when they discover how the rates of HAI in the private sector compare with the NHS. Infection rates for hysterectomies, for example, vary between 0.74% to 2.8% in private hospitals. In the NHS they are as high as 11%.
It is almost impossible for patients to make that comparison. Private hospitals include the information on their websites or are happy to give it over the phone. The matron of one told me proudly that its rate was 0% per 10,000 beds: “We often get inquiries and quite rightly so. I would want to know.” In the NHS the Healthcare Commission provides information on trusts but not on individual hospitals.
Even an NHS GP found it difficult to discover such information. He explained that patients are on the “choose and book” system, but choice was restricted to locality only.
The Tories agree that standards of information in the NHS are “lamentable”. They promise to provide the public with information on the “prevalence” of HAI – not only hospital by hospital, but also department by department. This information is vital. Competition and patient choice will do more than any government policy to force good practice up through the management hierarchy of the NHS.
Meanwhile, we have allowed authority to absent itself where it should be all important. Any politician contemplating healthcare reform must start with the basics. And the basics are a clean pair of hands.
Managing Not to Manage – Management in the NHS, by Harriet Sergeant, is published by the Centre For Policy Studies